The clinical effectiveness and costs of videoconferencing in orthopaedics between primary and secondary care were examined in an eight-month prospective, comparative study. The general surgery outpatient clinics of two Finnish district hospitals were compared: Peijas Hospital, with telemedicine, and Hyvinkää Hospital, without it. The three study primary-care centres referred a total of 419 adult patients to the outpatient clinics. The population-based number of referrals to Peijas Hospital was similar to that to Hyvinkää Hospital after adjusting for the proportion of older people living in the Hyvinkää Hospital municipalities. Of the 225 patients referred to Peijas Hospital, 168 (75%) were given appointments at the outpatient clinic of surgery and the rest of the referred patients received a teleconsultation. All patients referred to Hyvinkää Hospital were given appointments at the outpatient clinic. The direct costs of an outpatient visit were 45% greater per patient than for a teleconsultation, with a marginal cost decrease of EU48 for every new teleconsultation. A cost-minimization analysis of the alternative interventions showed a net benefit of EU2500 in favour of teleconsultations. The use of videoconferencing between primary and secondary care was modest in orthopaedics, although the use of this telemedicine method was shown to reduce direct costs and be cost-effective.

The clinical effectiveness and costs of telemedicine in improving the referral process from primary to secondary care were examined in an eight-month prospective, comparative study with one-year follow-up. The internal-medicine outpatient clinics of two Finnish district hospitals were compared--Peijas Hospital (PH) with telemedicine and Hyvinkää Hospital (HH) without it. The three primary-care centres studied referred a total of 292 adult patients to the outpatient clinics. The population-based number of referrals to PH (7.5/1000) from primary-care centres was twice that to HH (3.8/1000). Thirty-seven per cent of referrals to PH included requests from general practitioners for on-line medical advice (teleconsultation). Forty-three per cent of the total number of intranet referrals resulted in outpatient visits at PH, compared with 79% in the outpatient clinic at HH. Only 18% of the patients receiving a teleconsultation ended up in the outpatient department of PH within one year. These visits were mainly due to progression of chronic disease. No deaths or missed diagnoses could be attributed to telemedicine, but one diagnosis was delayed. The direct costs of an outpatient clinic visit in internal medicine (EU211) were seven times greater per patient than for an e-mail consultation (EU32), with a marginal cost decrease of EU179 for every new intranet consultation. A cost-minimization analysis of the alternative interventions showed a net benefit of EU7876 in favour of the teleconsultation process. General practitioners sought an outpatient visit for 130 of their patients, and advice only for another 77. On-line advice was nonetheless given in 108 cases, and only 88 patient visits were arranged. Eleven referrals were declined. The cost difference between giving on-line medical advice for the 108 cases and a visit to the outpatient clinic for the other 88 was less costly (by EU4140) than investigating the 124 patients whose original clinic referrals to the PH were not declined. Productivity in the hospital increased over threefold by using e-mail consultations instead of traditional outpatient visits. The wide interactive use of the intranet referral system between secondary and primary care improved clinical effectiveness, lowered direct costs, increased productivity and was cost-effective.

In Finland, a project designed to modernize processes and reduce the waiting list for joint replacement surgery has recently been completed. The new surgery arrangements for artificial joint patients were monitored for a period of 1 year. The new arrangements involved relocating the anaesthesia phase outside the operating theatre. The reorganization of the patient care process for joint replacement surgery succeeded in achieving a 50% increase in operations. While conventional operations can often be pushed up a notch with state-of-the-art technology, for example, this article supports the argument that process thinking can be exploited effectively to support new ways of work and improve productivity in health care. Paying enough attention to this at the planning stage can be vital to the success of new IT system implementation.

This prospective study is the first one of its kind carried out in Finland, in which a simple technological platform was developed to merge traditional text messaging with an electronic patient information database. The technology has been tested for relaying two-way treatment messages in psychiatry provided by a central hospital offering secondary healthcare. Text messaging was found to be particularly well suited for young people who have to travel to the outpatient clinic over long distances or who face the risk of social exclusion. According to clinicians, the text message reminders sent between the visits, which take place every 1-2 months, can encourage the young people in question to stay in touch more frequently, which will help to improve their relationship with the hospital staff. The project is still in the pilot stage, and so far the most important results concern the development of the operating culture and, surprisingly enough, legal aspects. From the legal point of view, the hospital had to equate text messages with phone communications. For this reason, it was not possible to put the text messages into a separate register and they have not been archived either. The success or failure of the new innovative healthcare solution may, therefore, depend on both technological aspects and legal factors.

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