Rheumatology patients on heavy medication need to be examined regularly to evaluate the pharmacological treatment, possible side effects and general wellbeing. To reach all the patients in the county, medical specialists in rheumatology placed at Nus previously staffed also the rheumatology departments of Skellefteå and Lycksele Hospitals once a week. A large part of the time was thus spent on travels instead of working with patients. Therefore, a rheumatology surgery was established in Skellefteå hospital in 2010 followed by Lycksele Hospital in 2014, both staffed remotely by specialists at Nus. The target group is patients with stable rheumatologic disease, those in need of regular control of anti-rheumatic drug therapy and those in need of short-term follow-ups. For this purpose, special rooms have been equipped with videoconferencing systems and a high-resolution video camera on a flexible stand. The operation is made possible by specially trained nurses and physiotherapists in the local hospitals, who work in a team with the rheumatologist at Nus. The local staff receives the patient and performs a routine examination before the connection to Nus is established. The specialist thereafter communicates with the patient via video and if needed, further examinations can be carried out with support from the local staff with or without using the high-resolution camera.

Besides leading to a more efficient use of the specialists, this work model contributes to skills development for nurses. For example, with this approach it becomes the nurses' role to listen to the heart and lungs and to investigate the status of the patient’s joints, which is an important part of the follow-up. It also leads to increased availability of specialist as several patients can be managed in the context of the local services. Virtual visits cannot completely replace face-to-face appointments, but works well for many patient groups and types of 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.

Many sparsely populated municipalities in the Västerbotten County have difficulties recruiting medical professionals to the primary care. The problem is also evident in urban primary care facilities, but to a lesser extent. These units are thus often dependent on temporarily hired physicians, a situation which entail unnecessary high costs, affect continuity and compromise the benefits of an established relationship between doctor and patient.

In 2014, the potential of implementing a “virtual” GP was evaluated in one of the rural municipalities of Västerbotten. The concept depends on GPs in primary care facilities with higher staffing, typically in urban areas, serving patients in the sparsely populated areas on a regular basis. During the pilot study, GPs from two urban primary care centres in Umeå staffed the virtual clinic. During appointments, the GP has support from a local nurse assisting the patient as well as the physician by facilitating necessary examinations and sampling. The concept was evaluated in a cottage hospital, where a room was equipped for the purpose. The room contains, in addition to standard equipment, a video conferencing system and a medical camera that can transmit images of e.g., skin and throat in real time to the GP. A digital stethoscope for heart and lung auscultations with real-time streaming capabilities will also be part of the solution. Evaluation of the concept shows that there are many types of patients and visits suitable for virtual meetings and patients who participated in the study had a generally positive attitude. Among other things, patients highlighted the advantage of meeting the same doctor during return visits, even if this meant a virtual appointment. The dependence of temporary staffing in the sparsely populated areas results in patients being used to meeting doctors they have never seen before. The goal is to deploy the concept in 2016.

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.

Ultrasound examination of the heart, known as echocardiography, is of major importance to establish or rule out certain heart diseases. Echocardiography is only offered at the county's hospitals and to address this limitation, researchers from Skellefteå hospital have developed a method whereby a cardiac ultrasound examination can be executed from a distance in conjunction with a cardiologist consultation. This is made possible by a robotic arm holding the probe of an ultrasound system located in Storuman cottage hospital, which can be remotely controlled by an experienced biomedical scientist at Skellefteå hospital with support from several video cameras. During the ultrasound examination, the patient is accompanied by a local nurse and can communicate with the operator through one of the video screens. When the examination is complete, the patients GP and the cardiologist join the meeting to evaluate and discuss the results. All communication, including video communication and control of the robot goes via the County Council's network. The image from the ultrasound system, along with the video from three cameras in the room, is sent to the operator via streaming technology.

The concept was developed within an EU project called HeartNet (2001-2006) and has subsequently been further developed and evaluated both in projects as well as in ordinary operations. The approach has been thoroughly evaluated and shows, among other things, a sensible use of economic resources and quality gains through significantly shorter lead times to diagnosis and treatment compared to traditional care. In 2014, a randomised controlled study with 38 subjects was published in the prestigious Journal of the American College of Cardiology.

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.

Storuman cottage hospital provides CBT treatment via video to patients in several municipalities in the sparsely populated areas of Västerbotten. The therapist connects to the meeting using an ordinary webcam and the patient joins either from the closest primary healthcare facility or by using a similar equipment at home. The first meeting takes place face-to-face and subsequent meetings via video. In addition to increased availability to the CBT therapist, this work model can reduce the vulnerability of the healthcare system by reducing negative impact caused by shortness of local staff, e.g., owing to illnesses or vacancies. In addition, the patient and the therapist reduce the need for long journeys, which have positive effects on the individual as well as the society as a whole through reduced risk of non-attendance, lower travel costs and reduced environmental impact. The service started as a pilot but is now implemented within the framework of the rehabilitation guarantee. In addition, since 2016 Storuman cottage hospital is participating in a pilot project in which patients receive CBT treatment by video in their homes via the national platform for support and treatment.

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.

Ten percent of the Swedish population suffers from chronic pain, which represents almost 60 percent of all long-term sick leaves. Pain involves suffering on many levels and can cause physical as well as psychological and social problems.

Each year about 320 people, mostly in the age of 18-65, with chronic non-cancer-related pain are referred to the Pain Rehabilitation Clinic at Nus. About 80 of these participate in rehabilitation programs. The program builds on various coping strategies, ergonomics and physical training and Basic body awareness is one of the methods used. The method has good evidence for lasting improvement of painful conditions, especially during group therapy. However, several long-distance patients refrain from participating in these programs as they find it difficult to be away from home for longer periods.

In 2011-2014, the Pain Rehabilitation Clinic participated in the EU-funded project ITTS by evaluating physiotherapy using video technology. This approach was new and the method is currently being adapted for introduction into the routine rehabilitation programs. As a result of the project, long-distance patients are now offered virtual participation in team-based or individual meetings with physiotherapists, psychologists, occupational therapists or social workers.

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 the very beginning of the 21st century, the Speech Pathology Clinic at Nus developed a novel concept for remote rehabilitation of patients with voice and speech disorders. The concept originally came about as the speech therapists were too few to cover the needs of the county. Today, this work model is well integrated in clinical practice and meeting patients via video is considered as natural as meeting them at the clinic. Remote rehabilitation is also a routine part of the speech therapy student curriculum.

Speech therapy is offered remotely to patients of all ages and for a large number of diagnoses, including aphasia, dysarthria and dyslexia. The location of the treatment can be the patient’s home or the nearest primary healthcare facility and thus offers a more equitable care as the availability is the same regardless of where the patient lives.
 
In addition, the speech therapists work more effectively and can equalise the queues to various treatment facilities by accepting patients from the entire county. Moreover, this work model permits a more intensive treatment regime, which has positive impact on the clinical outcomes. Remote speech therapy was part of the EU project ITTS and has since 2014 been established in several European countries, including parts of Scotland, Ireland and Northern Ireland.

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 Pathology Department at Nus participates in about 60 rounds every week in different areas. The haematology round, held twice a month via video, is coordinated by the centre for laboratory medicine at Nus and is part of the normal routines since the late 1990s. Hospitals in the northern region notify the managers of the round when they have patients to include in rounds. Regular participants are physicians from the Pathology Department and haematoma-pathologists at Nus, and haematologists from, for example, Sunderbyn, Östersund and Skellefteå. Occasionally, biomedical scientists and geneticists also join the round.

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 multidisciplinary breast conference is managed from Nus and includes Skellefteå hospital. The conference started already in the late 1990s and is one of the first rounds that allowed remote participation. The conference deals with patients with breast cancer or suspected breast cancer, and all patients are discussed at the conference before and after surgery/treatment in accordance with national guidelines. The round primarily addresses patients from Västerbotten but also includes patients referred from other parts of the northern healthcare region when needed.

At the managing hospital, radiologist, pathologist, oncologist, surgeon, contact nurse, surgical planner, research nurses and students are attending and in Skellefteå usual participants are surgeon, contact nurse and secretary. An important benefit of this work model is the multi-disciplinary character of the discussion leading to a better conference decision. Other advantages are skills development, improved dialogue between different medical disciplines and hospitals, and improved adherence to national guidelines.

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.

There is a lack of full-time nephrologists at the dialysis unit in Lycksele Hospital, thus specialists at Nus regularly perform rounds remotely with support from the local staff in Lycksele. The rounds are enabled through mobile videoconferencing equipment, which makes it possible to carry out rounds wherever it is best suited. The approach is now part of the routine services. During holiday season, the specialists also support the dialysis unit in Skellefteå Hospital, although to a limited extent. The work model was established in 2011 with support from the EU-funded project “Implementing Transnational Telemedicine Solutions” (ITTS) in which all three dialysis departments in the county participated.

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.

For more than a decade, the Centre of Medicine at Nus carries out joint rounds in renal pathology together with Karolinska University Hospital in Stockholm. Kidney biopsy specimens from patients in Umeå are prepared and sent to the pathologist at Karolinska. Once a month, renal pathologists at Karolinska connects to Umeå using video conference and discusses specimens and patient cases with local kidney physicians, residents and candidates. All patients in this diagnostics area are brought up on the rounds. Benefits include faster preparation, shorter lead times to diagnosis and skills development for staff at Nus participating in the rounds. Since 2014, Östersund Hospi-tal is included in the round.

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 many years, Nus and Sahlgrenska University Hospital holds joint rounds for patients from the Northern Healthcare Region who has undergone kidney transplantation at Sahlgrenska. The rounds are held every two months and currently include Östersund hospital as well. In case of clinical indications, renal biopsies are sampled from the patient at Nus followed by a discussion of the case with nephrologist and transplantation nurse from Nus, and specialized transplant physicians from Sahlgren-ska Hospital. On occasion, resident physicians and candidates are also involved. Main benefits of this work model are faster (and higher quality) processes, reduced lead-time to test results, and competence improvement of local 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.

Within the colorectal area, i.e., colon, rectal and anal cancer, multidisciplinary rounds have been carried out for a long time. The rounds engage pathologists, oncologists, surgeons, radiologists, contact nurses, and all patients from Umeå and Skellefteå are brought up on the round. Since 2009, it is possible to join the round remotely which is used frequently by participants from the hospitals in Skellefteå and Östersund. Thanks to these joint conferences, all patients are given the same conditions for treatment decisions, regardless of their place of residence. In addition to the equality perspective, an advantage of these rounds is that the patient is evaluated simultaneously by all relevant medical disciplines and is fully investigated be-fore the decision on treatment or surgery is made.

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 conjunction with the construction of the radiotherapy unit at Sundsvall Hospital in 2000, a multidisciplinary round known as distributed radiotherapy was established between Nus and Sundsvall Hospital. The aim was to make use of the experience from Nus radiotherapy and support the dose planning for patients to be treated in Sundsvall. Today, Sundsvall has a fully independent radiotherapy unit but the round remains, partly because it contributes to professional development of everyone involved. All patients planned to receive radiotherapy are brought up on the round, thus it contributes to a more equitable care. The round is held twice a week primarily with oncologists, nurses and physicians at both locations, and occasionally students.

In the field of radiation therapy there is also a national round for all children in need of radiotherapy. All hospitals in the country offering this treatment are involved. Rounds are held every second week and aims to ensure that all children have access to the best possible expertise and treatment. As it often concerns rare diseases, these rounds contribute to skills development among attendants, improved quality of care and patient safety by offering the possibility of a second opinion to the suggested treatment plan.

Common telemedicine rounds are also an important part of the National Centre for advanced radiation therapy, Skandionkliniken, in Uppsala. Skandion offers treatment with proton radiation to patients from across the country with tumours close to sensitive organs, for example head, chest and abdomen. The centre builds on distributed expertise and is a joint venture between Sweden's seven counties with teaching hospitals. Skandion offers, in addition to a national meeting place, a joint system for information and treatment planning to facilitate cooperation between hospitals further.

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.

Once a month, a regional dermatology round is held by the dermatology clinic at Nus with participation from the hospitals in Östersund, Sunderbyn and Sundsvall. The round utilizes videoconference with ability to simultaneously show clinical images and focuses on complex cases where the specialists want to discuss how to manage and treat the patient. Benefits include faster processing of patients and a more equitable healthcare in the region. The round is routine practice since January 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.

In the dialysis area, so-called access meetings are held via video conferencing and involve physicians and biomedical scientists from the physiology lab (fyslab), doctor and nurse from the dialysis unit and vascular surgeon and doctors from the IR lab. Activities include Nus, Skellefteå and Lycksele Hospitals. The aim of the access meetings is to plan access to the dialysis patient's bloodstream, and to share news and discuss new or updated procedures. The work model was established in 2010 and meetings are held four times a year, with 4-5 patients addressed each time. Better cooperation between professional categories and improved access care for dialysis patients are some of the benefits.

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.

This is a regional round involving patients in Northern Sweden with tumours in the lung and thorax. Since 2009, the lung clinics at Nus, Sunderby, Östersund and Sundsvall hospitals participate in the round with professionals in the fields of oncology, thoracic surgery, radiology, pathology and pulmonary medicine. Patients are brought up on this round both before and after surgery. The benefits of this approach includes investigation times for patients being reduced, that each hospital will have the opportunity to discuss their patients and that the responsibility for feedback to patients becomes clearer. The round is a forum where all relevant knowledge is collected and discussed, thus contributes significantly to improving the quality and assuring equal treatment for all patients in the region.

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.

Regional round established since many years that addresses patients from Northern Sweden with neuro-endocrine tumours. Frequent participants are Nus, Östersund Hospital and Uppsala Academic Hospital, although several other hospitals in the northern healthcare region are also invited. Among the Swedish university hospitals, the Academic Hospital is most experienced with this type of tumours. Participation in the conferences is enabled through videoconference and allows the participants to view x-rays and pathology specimens simultaneously. The round involves endocrinologists, radiologists, oncologists, surgeons and pathologists who discuss patient cases in order to reach consensus on best treatment strategy.

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.

A number of primary care facilities in the county provide patients with equipment to measure blood pressure and coagulation unsupervised, or with limited support from the staff. Traditional monitoring of anticoagulant therapy is based on venous blood sampling, which is time consuming for both patient and staff. The alternative of self-testing is based on a point-of-care device that needs only a simple capillary sample. The test result appears directly on the instrument and is, in addition, autmatically transferred to the patient's medical record where it can be assessed by the unit responsible for the prescription, either primary care or the anticoagulant reception at Skellefteå hospital or Nus. The concept contributes to considerably shorter time between sampling and ordination, reduces costs for sample management, saves time for the staff and patients are offered the freedom of performing measurements at their own convenience. Since 2016, the County Council is, in addition, subsidizing not only laboratory-based monitoring but also point-of-care equipment for certain patient groups to monitor INR at home.

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 Sweden there are five sarcoma centres responsible for diagnosing and treating tumours mainly in the extremities, abdominal and trunk wall, and pelvis. In addition, they handle certain tumours of the abdomen and underlying organs as well as the spine, chest, neck and shoulder region. Sarcoma rounds are held locally at Nus once a week for patients from the Northern healthcare region. About 400 patients are referred annually to the orthopaedic clinic at Nus and most of these are discussed in this round.

At these rounds, representatives of oncology, pediatric oncology, orthopedics, radiology and pathology participate on a regular basis whereas contact nurses and candidates participate occasionally. Depending on the nature of cases, other specialties, such as ear, nose and throat, hand surgery, vascular surgery or general surgery are also engaged.

To enable participation of pathologists at every round, a sarcoma pathologist currently takes part in rounds from his home in Gothenburg. The pathologist connects via video using two computers to enable visualization of information from multiple sources. This solution permits full participation in the round, as well as the ability to view histo-pathological images scanned by pathologists at Nus and accessed remotely via a VPN connection. The pathologist also participates locally from Nus on a monthly basis. The other hospitals of the Northern healthcare region can also connect to this round but have not used this opportunity at the time of this survey.

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 Interpretation Centre in Västerbotten offers support to people with deafness and blindness, and those suffering from a hearing imparement. In the middle of the 1990s, this centre started a project to offer writing interpretation remotely. The interpreter utilizes a video conferencing system or web cam and the patient watches the interpretating on a computer, tablet or video conferencing system. Information is transferred using a fixed or mobile broadband network.

Remote interpretation is typically carried out during a two-part conversation, for example during a visit to a phycisian or a phychologist but also during other types of meetings, including meetings with more than two participants. The current work model involves writing-, sign as support and sign language interpreters.

As Västerbotten is a large county an important benefit of working with distance technology is that the interpreters reduces their time on the road and have more time for assignments. Having the interpreter at a distance also seems to be better for certain patients, as this means fewer people in the room. Another advantage is that the county council can service other county councils with interpreter 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.

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