Paediatric Services in New Zealand are mostly provided through general practitioner and local hospital services, with the majority of full time sub-speciality services provided from Auckland. There are currently 870,000 children in New Zealand, that are unevenly distributed between the North Island (75%) and the South Island (25%).

The Ministry of Health and the New Zealand Paediatric Society convened a national review of Paediatrics Speciality Services, which produced a document called 'Through the Eyes of a Child'. Much progress has been made in considering the best way to provide all New Zealand children with access to appropriate speciality care, so that, in effect there is a single coordinated service in each specialty in New Zealand.

Tele-medicine and Tele-conferencing, although vital tools in developing this vision and a key recommendation in the Through the Eyes of a Child paper, were not deemed as a necessity and therefore fell outside of the Ministry of Health funding requirements.

Clinical staff from  various tertiary centres provide out-reach services to surrounding communities. Children requiring admission to hospital are then transferred to the major centres. It is estimated that with ongoing specialist support, many of these admissions could be managed locally with TelePaediatrics. TelePaediatrics therefore had the potential to reduce the required frequency of patient visits to specialist centres.

A number of smaller, provincial and rural communities have difficulties in attracting paediatric health practitioners because of distance, isolation from colleagues, and an inadequate local critical mass to support them professionally and personally. TelePaediatrics provides a means of addressing this professional isolation.

The goals in establishing the Service were as follows:
1.	Support the development of a National network to progress the best practise guidelines, planning for service delivery etc.
2.	Promote coordinated national speciality services in Child Health
3.	Provide a number of paediatric clinical services, which may include tertiary consultations and other clinical services between centres.
4.	Facilitate educational and professional peer support to paediatric units and services in New Zealand tertiary centres.
5.	Support multi disciplinary distance education and training opportunities for interested paediatric health practitioners.
6.	Provide national registrar training
7.	Establish national, paediatric medical grand rounds and other educational programs.
8.	Provide opportunities for child and parent health education.
9.	Support national planning, policy and research projects.
10.	Provide a foundation for the development of outreach clinical services from regional centres to their catchment areas.

To do this we broke down the ojectives into key developmental stages:

Stage one:	Create an Incorporated Society and enter into a Memorandum of Understanding with stakeholders.
Stage two:	Assess modes of carrier technology and equipment.
Stage three:	Develop the managed services model.
Stage four: 	Roll out of a truly national service.

The benefits from conducting the project in this way were to have all stakeholders buy-in to the same goal, an ability to make the decision of technology and technology delivery method from a central point and the creation of a Paediatric focussed and based network that looked at the needs of Children, their families and their caregivers. 

The network was designed on a secure and private IP network. The network initially operated via another carriers copper network but now operates via VSLs own network connectivity which is copper to 2mb and fibre for 2mb+.  Each unit is allocated 512kbps of bandwidth as the minimum standard with the ability to deliver High Definition Video Conferencing if the option is selected. 85% of the 130+ units currently operating are using 512KBPS links for 384kbps transmission speed. This is a user choice that is based on financial restraints but has proven acceptable for the forms of communication required.

At the Network core are two Polycom Video conferencing Bridges, they are a platform to support multipoint and gateway applications over any network, ATM, IP and ISDN. We chose the Polycom to accommodate our users changing multipoint needs and to allow a high degree of customisation based on capacity and manageability. Given that one of our users core requirements is to enable peer-to-peer collaboration across multiple connection types and across international borders we also provisioned a network gateway to allow on-network to ex-network (Web, Voice and ISDN) connectivity.

We standardised the network with Polycom Codecs allowing users to utilise the same technology irrespective of where they are. In saying that, we provide users with equipment designed for their requirement so do have a few other suppliers equipment to enable the delivery of some niche services.

We also utilise a Codian IP recorder to allow the recording and playback of video conferencing sessions securely and easily. This is used for numerous teaching sessions and to replay visiting expert lectures.

To ensure all of this technology could be supported on a national level, we developed our own managed service approach to ensure minimal human resources could support the plethora of technologies, users and geographical separations.

The method of doing this was:
Central video conferencing unit management via an appropriate management package. 
Configuration, management and updated software support of latest international standards to all network based videoconferencing systems.  
Help Desk; defined as a level 2 telephone, email and video-online response and quick fix support function. 
Real-time managed directories for all videoconferencing systems.
Centralised booking of the MCU (bridge) and gateway using online booking forms, email, fax or phone. 
Monthly reporting of video endpoint usage. Call Detail Records record the site called, by whom, duration, and accumulation of use over the month.  
Free on-call online training to ensure users have immediate access to support.

All bridging and management infrastructure is based in a secure, managed telehousing facility to ensure it operates in an optimum environment for maximum up time.

A number of outcomes, not all foreseen, have developed due to the above approach.
All users contact one nationally centralised point for any and all health video conferencing needs.
Most District Health boards have standardised to VSL providing all their VC services to save on local IT and support resources.
The NZ Ministry of Health has contracted to the service and informed the sector that it is the preferred provider of health video conferencing services.
3 awards have been won (Ministry of Health, Health and Disability Innovation, NZ ComputerWorld Excellence in Innovation; health,  TUANZ Innovation Award)
Other sectors approaching the service to design and implement video conferencing solutions based on the existing methodologies and processes.

Yes

Yes

1.	Equity of access to multi-disciplinary paediatric services to children requiring these services across New Zealand. Allowing clinicians to obtain the information required to treat patients from geographically separated colleagues. This aligns to improved personal and professional support, thus improving the ability to provide a continuum of health care. 
2.	The delivery of distance education and training opportunities for health practitioners in provincial and rural New Zealand. With specialists naturally gravitating to metropolitan centres due to the higher number of patients, the skills and information they possess can be shared nationally without the need for travel.
3.	Improved access to professional expert care for clinicians and patients without having to leave their local centre. This provision of access to the expertise required for managing a patients condition, without increasing the strain on the families requiring travelling long distances just for consultation has proven beneficial, especially to younger patients.
4.	The reduction of hospitals carbon footprint and the costs associated with travel whether it be financial or time costs. 
5.	A greater focus on treating patients in their own community, with access to national integrated services. This provides the opportunity to access the best care wherever that may be. 
6.	Contribution to developing the culture of national services. Allowing health care professionals to connect to colleagues immediately and effortlessly removes the barriers of time and travel. 
7.	The support of rural paediatric palliative care patients in their homes through the use of video conferencing technology. 
8.	Supported connectivity of, nationally based, community health organisations. Small health organisations with limited travel budgets have the ability to connect on a national level whnever it is required.
9.	Fostering and developing the use of video based ICT as a core component of communication in the health sector.  In 2003 video conferencing was seen as a nice to have and techy thing now it is seen as a core part of how health professionals communicate in their everyday work.

The best example I can give of a specific individual receiving benefit from this project is of a 14 year old paediatric palliative care patient who lived in a rural area of NZ. The patient lived on a farm approximately 7 hours drive to the treating hospital with her parents and a sibling.
Unfortunately the patient had cancer and was diagnosed as palliative with an expected 3 to 9 months to live.

The patient required regular contact with specialist caregivers to manage pain, medical complications and psychiatric support.
Initially this would mean regular round trips of 20+ hours with one parent.

It is well accepted that children, young people and their family receiving palliative care should receive this care within the home environment. This is particularly relevant to those living in rural or isolated communities with both limited paediatric and specialist palliative care support. 

To enable the patient to spend her final few months at home, in an environment that provided better emotional and family support, we designed a dedicated videoconferencing solution that connected the child and family directly from their home to the palliative care team in their base hospital. We installed desktop video conferencing systems that operated over our secure broadband network. 

We had great assistance from out telecommunications provider to install bandwidth into a rural site that was not on the national grid. We had to think outside the box and ended up actually running the cable for connectivity through a neighbouring farm that could access the network. We had support from the neighbour as he kept his cows out of the field the cable ran through..

The technical solution itself was a personal VC unit (Polycom VSX3000) at both the patient and hospital ends. This allowed 1-4 people at each end meaning that the patient could have the family and/or the local doctor at one end and the nurse specialists could have the clinical expertise with them at the other. 

Having the VC unit at home meant that the 20+ hour trips ceased as the specialist could VC in on a regular basis to the family and local medical professional. This meant that pain management medicines could be prescribed by the local professional with clinical support from a palliative care specialist. 
As the patient had spent many months being treated in the hospital, there was an existing rapport between her and the nurses. The patient would often make a video conference call to the nurses in the evenings, which allowed the nurses to keep abreast of the patients health in a relaxed and conversational way which worked well for both patient and caregivers. 
As the patients health deteriorated the family and clinicians decided they would manage the process remotely. For the last month of the young ladies life, instead of being in a hospital far way from her family and friends, she was at home surrounded by them with support from clinical professionals based in another city.

It was a tough thing to know that when the VC unit was turned off the young lady had passed away but we received a card of thanks from the family telling us that the solution made their daughters last few months much better than it ever could have been if she was in a hospital.

This network is the first of its kind in NZ, where health focussed VC networks exist around the world, there had never been a nationally focussed, fully supported network of any kind in health in NZ. 
The only? In NZ yes, there have been numerous people who have tried to develop a similar solution but have failed in the health environment.
The best? Going by the awards we have won and the growth we have had over 6 years (8 units to 130+), it could be seen as the best but in the small environment of NZ, comparative networks are not there to use as a bench mark. I believe it could be seen as the best because of a focus on user needs and a willingness to work in partnership.
Effective Application? YES! From the services inception being effective with the resources it had was paramount. Whether they be financial, human or process resources, each had to be at its most effective. The initial NZTPS board was made up of Paediatric clinical personnel not business managers. This meant the focus was on user requirement for the benefit of patients and clinicians. All solutions were designed around an articulated need, not a financial or business process requirement. This created a requirement to be operationally effective; with only one staff member to conduct every aspect of the project, effectiveness and efficiency were an absolute necessity. This has been carried on through the years and although the staff level has grown to 8, ensuring that the network and its solutions operate effectively for the benefit of the users still remains fundamental to the success of the project.

There were a plethora of obstacles that were in fact stepping stones to creating a successful solution.
There was no previous telemedicine technology solution in NZ health sector. This was the first of its kind in the country. Not having a blueprint or an existing benchmark for its development meant that there was no wrong answer.
21 different District Health Boards. Each user required a different delivery mechanism or technical configuration. This meant we developed solutions to work in any environment. 
User experience and bias. Perceptions of poor video, poor audio, unreliable, too technical. Because this was a new technology, there was no previous knowledge of the progressions made in the medium.
Busy clinical teams that were time poor and outcomes driven. Building communities of interest by identifying clinical leaders who were early adopters had a flow on effect that drove specialties into using the technology through peer marketing rather than senior management command.
Financial restraints of the health sector, funding was/is tight so having a sponsor that allowed the service to operate virtually free of charge for an initial period meant that the commitment was in their time rather than their pocket.
Risk aversion. Health professionals will often tread carefully with new technologies or methods of doing things. It took a great deal of hand holding to have them accept what is now seen as a core communication tool. Initially it was done by having national broadcasts of clinical grand rounds that were previously only available in person to people in the leading medical centre in the country. Broadcasting these live each week under the guise of a lunchtime broadcast like a TV show meant it wasnt anything they had not seen. These started in 2004 with two hospitals about 15 external participants and continue today with 20 external hospitals and around 300 external participants.
 

As can be seen in the above, the resistance was on a number of levels but in working through them in an open and outcome focussed way, the initial resistance and obstacles became the projects greatest promotional tool.

The project gained the respect and support of clinicians as it assisted with communication to colleagues, with Information Services staff who could focus their human resource on core hospital requirement rather than VC and business managers that could see workforce development possibilities grow and travel savings. 

Exceeded

With the network connecting every District Health Board in the country on a secure, interconnected and standardised platform, only small changes are required to offer other services between each such as web, file transfer and amalgamation of technology platforms. It also provides better connectivity for external suppliers of technology services to connect to multiple DHBs as they can enter at one point for multiple connections rather than separate connections to each point.
With this network being the standard for all DHBs video conferencing, store and forward telemedicine or any other telehealth application can be developed in a secure and supported environment.

The initial uptake was slow so we focussed on driving and fostering usage of the medium in a way that was unobtrusive, easy and accessible. It meant that we hand held for a period of time but once they initial groups of users had become comfortable they became our biggest and best champions and development tool. 

The innovation of centralising everything such as equipment support, bridging and standardisation of platform was accepted very quickly as it was identified early on that it was the best option to ensure the longevity of the project.

Having partners in technology such as Polycom ensured new and innovative solutions were readily and accessibly available which gave users the confidence that innovation was standard operating procedure not a coincidence. When the target audience believe in what you do, how you will do it and that the outcome will be what they want, the timeframe for accepting new innovations reduces markedly.