Video consults for distant patients offer many advantages for patients who live long distances from their specialists. This article is written by Nick Brook and Rajiv Singal, and covers many of the issues for this exciting development in healthcare.
What is Video Telehealth?
There is nothing clever about Telehealth, and it’s remarkable that uptake has been so slow. The technology, as voice-over-internet protocol, has been available for a long time - Skype was released 11 years ago. Telehealth simply uses similar or identical technology to link doctors and other health professionals to patients. Travel for remote patients and associated costs are reduced, and in urgent settings, Telehealth can provide rapid access to expert medical opinion.
What are the advantages in Big Countries – Australia and Canada?
Australia is a big place; the sixth largest country after Russia, Canada, China, the USA, and Brazil. Its land size is 7,692,024 km2 with a small population (24.5m). Eleven percent of the population are classified as living in remote/country/rural areas. Canada shares the same challenges as Australia with a similar population spread out over an even greater area.
There is a marked disparity in health provision between urban and remote areas of Australia, which is extensively discussed elsewhere.
This disparity relates primarily to the practicalities and economics of provision of comprehensive health care in remote areas, and is by no means unique to Australia. In Canada 80% of the population lives within 150km of the US border. With borders that extend past the Arctic circle, the needs of small isolated communities become obvious. Travelling great distances can also be hindered by unpredictable, harsh weather during the winter months.
South Australia is a stand out example of how and why Telehealth can help distant patients. SA has a population of only 1.67m. The Australian Bureau of Statistics give the following figures for population distribution:
|South Australia||Major Cities||Inner regional||Outer regional||Remote||Very remote|
SA has traditionally had a close relationship with the Northern Territory in terms of health care provision, and many patients travel to Adelaide from NT for secondary and tertiary care. You can see that travel distances involved for some patients are huge. Much of the care provided must, by its nature, be delivered at metropolitan centres, but much work up and follow up could be performed by Telehealth, reducing costs (economic and social) for patients and government.
As an example, a typical series of encounters for a prostate cancer patient, from GP referral to surgery, is as follows:
- Initial consult
- Biopsy appointment
- Biopsy results
- CT/MRI/Bone scan (often cant be arranged at the same visit)
- Appointment for Results
- Second clinic for decision
- Pre-anaesthetic clinic
- Day of surgery
Those highlighted in orange could possibly be replaced with Telehealth appointments. When we consider that some patients make a 2000km round trip for a hospital appointment, the potential advantages become crystal clear.
As well as distant patients, there are potential advantages for Residential Aged Care Facility (RACF) residents, and Medicare Australia has made special allowances for Telehealth to such patients.
It similarly follows that after surgery and the initial recovery phase that many traditional post operative visits could be conducted electronically, particularly when a stable situation is apparent and monitoring of blood work is the main task. Another good fit for urology would be stone follow up for patients on surveillance programs for renal calculi.
Are there any disadvantages to Telehealth?
Inherent in electronic communication is the inability to make physical contact with patients. Nothing can replace an in-person consultation for building the patient-doctor relationship and establishing trust. A handshake is the foundation of consultation, and the ability to examine is lacking. If a patient-end doctor is present, this can be circumvented to some extent, but the quality of interaction is less. Nevertheless it is clear that patients are generally grateful for email access with their treating physicians. A robust Telehealth service would potentially improve upon that.
Co-ordination of appointments can be challenging, as there should be a health-care provider at the patient end. Patients may still need to travel large distances to get to a health care provider with Telehealth facilities.
Electronic communications can break down, although this is rare. More important are potential security issues, which are discussed below.
Why has it taken so long to get this going?
This is difficult to answer. Perhaps established patterns of behaviour are hard to break; as medics, we have become wedded to the in-person consultation. Clearly, advantages and disadvantages of both in-person and Telehealth consults need to be weighed carefully for individual patients.
Set-up costs are minimal, and most specialist and GP practices will have easy access to the readily available technology.
Although government has been leading the Telehealth drive, patient demand is increasingly a factor in health care policy, but rural/country/distant patients may be the least vocal in terms of health care requirements, despite often having the greatest need.
Financial Incentives/reimbursements for Doctors
Various financial incentives are in place from Medicare Australia, through the Medicare Benefits Schedule, with the aim of driving Telehealth uptake. These are categorised as follows:
- Telehealth On-Board Incentive
- Telehealth Service Incentives
- Telehealth Bulk Billing Incentives
- RACF On-Board Incentive
- RACF Hosting Service Incentives
These taper over time, and more information can be found here.
Interestingly, rebates for Telehealth are actually higher than for in-person consultations, and this is said (by Medicare) to reflect the infrastructure costs involved.
Systems in use
There is a range of complexity in Telehealth technology. At the top end, very fast connections (where available) combined with fully integrated complex software and hardware allow monitoring of medical information from skin, eyes, ears, pharynx, heart, lungs and other parts of body. Advanced telemedicine can also manage ECG, spirometry, dermatoscopy, pharyngoscopy and endoscopy sessions.
Less complex and costly are installed systems, which essentially build on business teleconferencing platforms. Digital quality is high, and this standard is needed if there is need for diagnosis beyond history taking. These systems still require substantial investment and on-going cost.
The easiest to install, run and pay for are widely utilised software programs such as Skype and Facetime. Most computerised practices will be able to set these up easily, and most health care providers are conversant in their use, so no additional training is required. Quality can be low, and these systems are only really suitable for communication based on discussion and history taking. For example, clinical signs cannot be reliably demonstrated. However, on the principle of ‘the greatest good for the greatest number’, this method of Telehealth probably will have the greatest uptake.
Just as in a standard face-to-face consultation, privacy (and digital security) must be absolutely respected. Medical records made at the time of video consultation are recorded and stored in exactly the same way as a standard consultation.
The more costly systems have security built into their frameworks. Systems like Skype and FaceTtime have raised some concern.
The Royal Australian College of General Practitioners has produced an advice document on using Skype, which can be viewed here.
Briefly, that document outlines the concern that the routing path used by Skype often involves data transfer outside of Australia, through countries that may not have the same privacy laws as Australia. For this reason, the RACGP advises that medical content, such as still images or desktop screen shots should not be exchanged during a video consultation using Skype. The RACGP also highlights that configuration is required to ensure that the Skype default of retaining history files, which record all episodes of communication, are set correctly as these files are potentially accessible with spyware. The RACGP do not have a FaceTtime policy.
Both Skype and FaceTime employ Secure Real Time Protocol (SRTP) using AES (Advanced Encryption Standard) 256-bit encryption (also used by the US Government to protect sensitive information).
Likewise, Wi-Fi and wired systems at a health care practice must be encrypted as a further layer of security. As both of these encryptions work separately, it would be very difficult indeed for these systems to intercepted by a third party.
In summary, it is highly unlikely (although theoretically possible) that a Telehealth consultation could be breached, but the risk is probably no greater than the risk of standard computerised medical records being breached by a ‘professional’ and determined hacker. It is the health care provider’s responsibility to ensure the privacy and security of the consultation, that the technical system is reliable, secure and fit for clinical purpose, and that risk management protocols are in place.
The foreseeable future
Increased utilisation of Telehealth may be one of the strategies to help address the huge and unprecedented growth in Healthcare need, which is forecast to continue.
The tables below are taken from the MBS Telehealth Statistics.
The first demonstrates a steep uptake of Telehealth since 2011, but perhaps a developing plateau, which would be typical of saturation of the technology savvy medics. Hopefully, over time the service will expand further, but this will rely on patient acceptance and satisfactory feedback.
The second table shows claims processed by specialty, and it is encouraging to see urology near the top. Further expansion in our specialty will be partly patient driven, but also requires support from specialty bodies.
The Australian Telehealth Society has produced a position paper on a National Telehealth Strategy to 2018 that is worth reading.
Essentially, the aim of Telehealth is to improve access to health care for patients who are disadvantaged by their location – its all about taking health care delivery in the direction where we can better scale the doctor to patient time.
Nick Brook is an Associate Professor in Surgery at the University of Adelaide, and Consultant Urologist and Director of Urological Cancer at the Royal Adelaide Hospital in South Australia. You can follow Nick @nickbrookMD on Twitter
Rajiv Singal leads the Surgical Robotics Program (jointly run by TEGH and Sunnybrook Health Sciences Centre) and is an Assistant Professor in the Department of Surgery at the University of Toronto. He supervises the Clinical Endourology Fellowship program at TEGH under the umbrella of the University of Toronto.
You can follow him @DrRKSingal on Twitter