Video

28
November
2014

TeleHealth - A Revolution in Healthcare?

TeleHealth - A Revolution in Healthcare?

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.

Australian map showing population density.

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 AustraliaMajor CitiesInner regionalOuter regionalRemoteVery remote
 72.7%12%11.5%2.9%0.9%

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.


Security issues

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.

Number of Providers by Selected Subspecialty - claims processed as at 31 March 2014

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.

Services by Year and Quarter – claims processed as at 31 March 2014

The Australian Telehealth Society has produced a position paper on a National Telehealth Strategy to 2018 that is worth reading.


Summary:

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


Categories: Video, Updates

29
April
2014

Stereotactic Ablative Body Radiotherapy (SABR)

Stereotactic Ablative Body Radiotherapy (SABR)

Our First Guest Blog for May 2014 is by Dr Shankar Siva, a Radiation Oncologist from The Peter MacCallum Cancer Centre in Melbourne. He discusses the new technique of Sterotactic Ablative Body Radiotherapy for kidney cancer in patients who are not medically fit for surgery. This new approach is still in a study period, but may offer cancer control to patients who do not have other treatment options.


Shankar, can you explain what Stereotactic Ablative Body Radiotherapy (SABR) is, and what advantages it has over other forms of radiotherapy?


Stereotactic ablative body radiotherapy (SABR) is a high precision radiotherapy technique that involves between 1 and 5 treatments. This is very different from conventional radiotherapy that involves daily radiotherapy for up to 8 weeks. It is non-invasive, painless, delivered without any need for anaesthetic, and conveniently does not require in-patient hospitalisation. SABR requires high-tech radiotherapy equipment for safe delivery, such as motion management for the tumour, accurate image guidance, and robust immobilisation. When delivered correctly, SABR can achieve submillimetre accuracy. Because of its precision, the SABR technique allows for much higher biological doses than can be safely delivered using conventional radiotherapy techniques. As such, most studies in sites such as the brain, lung and spine report cancer control rates in the order of 90% or greater after SABR.


Sterotactic radiotherapy for some other types of tumour has been around for some time. Why has it only recently been looked at for kidney tumours?


Stereotactic radiotherapy was first devised for brain tumours by Swedish neurosurgeon Lars Leksell in 1951, who termed it “radiosurgery”, so yes, it has been around for a very long time! Cranial "radiosurgery" was performed by using a rigid frame around the skull which allowed for accurate delivery of the radiation dose. However, tumours in other organs such as the lung, liver, and kidney are all highly mobile due to normal breathing or from the pumping of the heart. Only recently have technological advances allowed us to account for and manage tumour motion during radiotherapy delivery. The kidney in particular is a challenging organ, as it is quite mobile and surrounded by many sensitive organs.


Which group of patients is likely to be suitable for this treatment for kidney tumours?


Surgery is still the standard of care for patients with kidney cancer. However, kidney cancer is typically a disease of the older population, with the average age of diagnosis being 65 years of age. Some patients have other medical conditions which make invasive procedures potentially risky, particularly those patients who may have significant pre-existing kidney dysfunction, are risky anaesthetic candidates, or have heart disease and are reliant on blood thinners. In light of this risk, other procedures such as SABR and radiofrequency or microwave ablation have emerged as treatment alternatives for inoperable patients. In contrast to SABR, the disadvantage of radiofrequency ablation and microwave ablation is that those techniques can typically treat only treat smaller tumours, require the insertion of electrodes through the skin into the kidney (invasive), and are not as effective when tumours are close to blood vessels. On the other hand, the disadvantage of SABR is that it is typically restricted to patients who have not previously received radiotherapy to the upper abdomen. Otherwise, we expect that most patients who are not suitable for surgery on medical grounds may be eligible for treatment using the SABR technique.


What are the potential side effects?


In the early period after treatment, we expect that most patients feel tired. There may be some nausea, or loose bowel actions. Some patients may experience some reflux or heartburn. We typically prescribe preventative medications to help with these side effects. There may be a mild skin reaction, similar to a very light sunburn, particularly around the back. These side effects usually resolve within the first 2-3 weeks, and we expect all of these side effects to be resolved by around 6 weeks post treatment. The longer term effects of SABR in the kidney are less well understood. There is a potential for decline in kidney function, rise in blood pressure, scarring or narrowing of the bowel, or very rarely ulceration of the bowel or stomach. To date, studies have shown that the risk of severe side effects to be less than 5%.


This treatment is currently part of a study at the Peter Mac. What do you think the future holds for this treatment for kidney tumours?


We have pioneered this technique in Australia through the FASTRACK clinical trial, one of the few clinical trials using SABR for localised kidney cancer in the world. This study is expected to be complete later in 2014, and to date the results have been very promising. We would like to make this treatment accessible to all patients in Australia. However, the problem is that technology is very complex and varies from centre to centre. The Peter Mac is one of the largest radiation oncology institutions in the southern hemisphere and an Australian leader in the SABR technique, so we are not certain whether our results can be immediately reproduced in other institutions across Australia.

The next phase in our research program is to lead a multicentre study of SABR for kidney cancer involving multiple cancer centres across Australia. All the treatment plans will be centrally reviewed by our team at the Peter Mac for quality assurance, in order for this new treatment to be safely introduced across Australia. If this study is successful, I imagine that stereotactic radiotherapy will become a readily available treatment alternative for inoperable patients with primary kidney cancer.


Click this link to display a news item and video on the SABR technique.


Dr Siva is a Radiation Oncologist, Research Staff Specialist and NHMRC Scholar at the Peter MacCallum Cancer Centre in Melbourne. His major research interests are in high-tech radiation delivery and radiation biology. He is the lead clinician of the stereotactic body radiotherapy program at the Peter MacCallum Cancer Centre, and coordinates the first dedicated Stereotactic Ablative Body Radiotherapy (SABR) clinic in Australia. He published the first original research using the SABR technique in Australia. He serves on the Radiation Oncology Research Committee (RORC) of the Royal Australian and New Zealand College of Radiologists, on the renal subcommittee of the Australian and New Zealand Urogenital and Prostate (ANZUP) trials group, and as the radiation oncologist on the Management Advisory Committee (MAC) of the Australasian Lung Cancer Trials Group (ALTG). He is the principal investigator of multiple radiotherapy clinical trials of SABR in the context of lung, kidney and prostate malignancies.

Follow this link for more information on Dr. Shankar Siva


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