John Wilson: Digital inevitability

IT is encouraging that recent research in the MJA and a subsequent news story in MJA InSight have created so much interest in the value (or otherwise) of telehealth.

What should be our priority in pursuing telemedicine — to enhance clinical care, achieve cost–benefit advantage or to meet society’s needs?

There is no doubt that digital solutions do not always have instant acceptance. One prime example is the personally controlled electronic health record (PCEHR), which has been contentious more for its promise to deliver than its potential value.

Few will argue that the internet has changed "the way we live, work and play”. There is universal acceptance of digitally recorded, formatted and communicated information in all aspects of life. It is a sequitur that digital electronic health records will achieve acceptance with one format eventually emerging above others to serve medical needs.

Much can be learned from a study of the British NHS experiment in digital information transfer.

This top-down implementation resulted in a very expensive lesson in understanding the marketplace. Practitioners either did not understand the value of digital records, or did not have a clear concept of how to integrate them into their workflow.

The analogy with the telehealth and PCEHR introductions in Australia is unmistakeable.

Maturity modelling has shown that a proven concept can only be adopted when the community is educated, uses and then has ownership of the technology. An old-fashioned example is the scalpel. In skilled hands (educated, uses then owns) it is a great instrument for healing, but the risk of damage is high when not appropriately used.

Traditionalists will argue that telemedicine tools are unnecessary and create unplumbed liabilities. Yet almost all information transferred today is in digital format — words, images and numbers on servers around the world are connected by copper wires or fibre networks.

Medical students of today are the consultants of tomorrow and their IT capability is a necessary attribute, rather than a desirable skill, to be successful. An appropriate training framework is essential to maximise the opportunity provided by telemedicine.

Telemedicine is in the indeterminate zone right now. Despite initially generous incentives and rebates available through Medicare Benefit Schedule item numbers, uptake has been slow.

Medical colleges and a range of non-government organisations have actively promoted telemedicine as a way of providing better access to medical care. In other words, maturity is being developed in the target population.

It must be understood that telemedicine is most likely to be accepted as an additional way to access care, rather than a substitution.

Banks in Australia initially went down the path of substituting service with internet options, only to find that regulators and the community did not accept the social experiment. A change in policy followed with internet banking available as an optional alternative to face-to-face services. However, the reality is that passbooks are fading and teller’s queues are dwindling.

The swinging pendulum of social acceptance is totally dependent on timing.

It would be a mistake to assume that telemedicine could replace face-to-face consultations. Telemedicine may be able to closely replicate history-taking by skilled operators, but cannot (so far) perform physical examinations.

High-capacity broadband can deliver quality service to the home for those disadvantaged by distance, disability or social circumstance thereby meeting the needs of most doctors and patients.

While there are limitations in some areas of practice, gains can be made in the management of chronic and complex disease, early discharge from hospital and in early assessment of acute events in remote locations.

So with potential gains, but possible liabilities, how do we solve the digital dilemma?

The centre-to-centre solution described in the MJA telemedicine article is the beginning. Centre-to-home evaluations will follow.

A solution from the middle out, rather than top-down or bottom-up, will more rapidly determine success for systems that are currently working in Australia.

Progressive familiarity with digital technology together with skill-enhancement programs will help telemedicine find its right place, as the telephone did more than 150 years ago.
 

Professor John Wilson is the head of the cystic fibrosis service at Alfred Health Melbourne, chair of the Royal Australasian College of Physicians education committee and an RACP Board member. His research interests include the application of electronic health records to medical systems.