Distance Consultation: collaborating between specialist and primary care

Norrbotten County, Sweden
Luleå University of Technology

Norrbotten County is situated in the northernmost part of Sweden and covers 25 percent of the surface of Sweden – as large as the area of The Netherlands and Belgium together with a population of 250,000 inhabitants. Norrbotten is the least populated region in the European Union, with a population density of only 2.6 people per km². This means that many residents have to travel far to get access to a specialist in hospital. A need for health services with high accessibility, medical safety, quality of healthcare and productivity has therefore been created. There are 36 primary healthcare centers (PHC) and five hospitals in the county. The main hospital, where most of the specialist care is located, is situated in Luleå. This means that for many patients and their relatives there are long distances to travel to see medical specialists.

During a period of ten years referrals from general practitioners to the dermatology department at Sunderby hospital increased from 2,100 referrals per year to 3,800 per year. The waiting time for patients to doctor visit increased and in 2007 the waiting time to see a dermatologist was 18 months. There were too few appointments to meet the increased need. The care process and patient flow were not optimal, neither externally towards primary care nor internally within the dermatology department. There were many re-bookings and cancellations of appointments since the time for appointment did not fit into the patients’ schedule. It was also difficult for the patients to reach the reception via telephone. The dermatology department started an improvement work to optimize their care process and patient flow and did improve their results. Despite this, the number of referrals continued to increase and the doctors and staff felt this system needed further improvement to fully meet the needs.

Based on a needs assessment an exploratory study was conducted by Luleå University of Technology (LTU) and the Center for Distance-Spanning Healthcare (CDH) in 2008 in order to examine the conditions for collaboration between primary care and specialist care. It examined how ICT could be used as a tool for consultations on distance between Primary care and Specialist care. A workshop – based on the results – was arranged with participants from primary care, specialist care and LTU/CDH.

Clinicians, managers and researchers gathered and discussed which disease areas that would benefit the most by increased use of ICT as a tool for increased collaboration. During the Workshop the need of consultations between dermatology department and primary care was revealed, as well as highlighting the need for competence-raising measures and a transfer of knowhow from the consulting dermatologists to the General Practitioners in order to better meet the needs of the patients when they need care and on the optimal level of care. After the workshop a project team was put together with doctors, nurses from primary care and dermatology department, staff from ICT department, researchers from LTU/CDH (EIC) and a Process Development Manager from NLL. The Project team agreed to start a Pilot project testing consultations on distance in real time between five selected PHC and the Dermatology department. The pilot went into effect in January 2010.

How does this Telehealth program work?

A Fact Electronic patient record (VAS) helps synthesize healthcare administration…

This program is supported through the development of Norrbotten county council’s (Norrbottens Läns Landsting, or NLL) own electronic health record system called VAS. The development of VAS started early in 1990 and is today also used in the County of Halland and the County of Jämtland. In total VAS covers 670.000 citizens in Sweden. VAS is a complete EHR system including the healthcare administration and is used in all hospitals, PHC and dental care centers in the County of Norrbotten. The development is done in close co-operation with the users, and it provides tailor-made tools to assist in the planning, management and monitoring of virtually all healthcare activities. VAS supports the manifold needs of healthcare professionals working in primary and specialist healthcare, in PHC and with hospital based in-patient and out-patient activities. Consisting of well integrated modules, the system provides an unbroken chain of information. The core module is the patient’s EHR which can be accessed from all hospitals and healthcare centres in the county. Other functions include internal electronic referrals of e.g. lab results, electronic prescriptions and tools for the planning and follow up of all types of care. All referrals between county council units are transmitted electronically within VAS. The involved care-provider always has correct information available whenever needed. VAS is used by all the County Councils personnel.

…feeding into a hybrid approach to consultative care

The GP meets the patient during an ordinary appointment. But instead of sending a referral to the Dermatology department an appointment for a consultation on distance is arranged. The appointment is set in the electronic health record, VAS, via a secure message function. The times for consultations were scheduled every Tuesday morning, and every very individual consultation lasted on average between 10 to 15 minutes (whereas a regular outpatient visit at the dermatology department normally lasts 30 minutes). The consultation is held via a PC based videoconference solution from Polycom called CMA desktop. The webcam used is a standard model (Logitech). The camera gives a picture quality that is good enough for a Dermatologist to give recommendations for further treatment and processing. The dermatologist examines the patient and gives instructions to the GP on how to move the webcam during the examination. During the session the dermatologist gives recommendations for treatment in dialogue with the GP and the patient. Documentation is made both by the GP and the consulting dermatologist. When needed, there is also a possibility within the electronic patient record, for the both doctors to read each other’s documentation afterwards to reduce the risks of malpractice and misinterpretation.


For patients particularly in rural areas, consultation at a distance implies that less time is spent on travelling to a specialist for consultation at the hospital. Furthermore, close relatives or family member do not have to take time off from work to accompany the person to a consultation, as a consequence cost for travelling is reduced. There are also a number of environmental benefits.

Preliminary results show that patients appreciated to have their own primary health care physician by their side at the consultation. The Patients expressed for example that the consultations on distance are good and feel safe. In addition they state that it also saves time since travelling is avoided.  Furthermore, preliminary result show that primary health care physicians expressed that they had benefit of learning from the specialist and also that they were given the same information as the patient at the same time as the patient. The GP´s expressed that it is an advantage that there is a dialogue online with the Dermatologist and the patient since all the questions can be asked and answered directly.

The Dermatologists state that there are multiple positive effects; less referrals and shorter waiting time, easier for the patients – less travelling, the possibility to discuss with the GP to give advice and also teach them at the same time. Other benefits are the collaboration between clinical practice within healthcare and research at the university and also better/increased collaboration between primary care and specialist care. During the Pilot project a total of 145 consultations on distance were performed (January 2010-June 2011). And there is an interest from several PHC to get access to the service in a near future.

That being said, one disadvantage with the set-up of the service today is that the patient needs one extra visit to their GP to take part in the consultation, since the appointment needs to be scheduled in advance. In the future there could be a possibility that the dermatologist on call is available for consultations at one time to avoid the extra visits.

E-Health Innovation Center – EIC

Luleå University of Technology (LTU) is the host of the e-Health Innovation Center (EIC). The EIC creates innovative products, services and processes available in a unique research environment that combines the health sciences, system science and electrical engineering. Scientific communities have merited through international research projects and have industrial growth and products as target. It is internationally known as a center of excellence in the areas of health and welfare, where information and communication technology (ICT) is used to give people the best possible care. The center formation will be an important resource to try out new solutions in health care and support for wide dissemination through education and cooperation with the thriving global e-health sector.

(August 2011)

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