Issue 37 / 30 September 2013

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.

5 thoughts on “John Wilson: Digital inevitability

  1. Dr Philip Dawson says:

    top down implementations are unlikely to be successful. radiology and pathology practices australia wide are now sending results, and allowing images to be viewed online, eliminating the need for paper, and chasing results. This doesnt need NBN, it works fine even on a slow 1mbs connection. But they wont accept electronic referrals, and we are forevever reprinting paper referrals for radiology for patients who lose them. same for scripts- all goes electronically to HIC, but chemists still must have that bit of paper, and so the chase for the lost script, or did they take too many or what happened to the pills goes on. The local public hospital now sends all its discharge summaries electronically, which has reduced our scanning by half. but they wont accept electronic referrals, we still have to print and fax. and each department wants a different referral template, we cant just write a letter. Specialists are slowest to adopt IT-while they love looking at images online now, they wont look at setting themselves up for receiving and sending referrals and letters electronically for teleconsulting we use anywhere healthcare and it works brilliantly, we get a list of specialists, specialities and approximate waiting times, they arrange all the bookings once we send (fax!) a letter.why cant hospitals do something like this? HD webcam gives good images for a consult. we have 10 patients in the CSIROs telemedcare trial, it too works well. If we can get two way electronuic communication going everywhere and cut the paper SOON please, we shall be very pleased, hybrid systems are a problem. If the banks, insurance companies, stockbrokers etc can all do it why cant we?

  2. Ted says:

    Just one comment to mentally chew on:  Most of us are suffering from  “Technology-Obsessive Disorder” (TOD).  We drive, juggernaut style, towards solving the world’s problems.  What is not fully appreciated by the burgeoning “Face-Book generation”, however, is the true longevity of digitized data (id es, Infinite).  Whilst I once “programmed computers” back in the dark ages, data storage technologies were in their infancy, as well, and no sinister possibilities crossed my pristine cerebral cortices. I stand before a very different “digital landscape” now, however.  Prior to running head long off the “electronic health record cliff”, we as sovereign human beings might well consider what happened to that result from the quick genetics test you once had performed, when it is “released” into the “electronic ether”…  What will your great grand-daughter think of you when she, and her lineage have been forever tainted by your naivete?                                                                                                        

  3. Graham Row says:

    How refreshing to read a sensible contribution to “telemedicine”.  To keep things in perspective one should acknowledge that the Reverend John Flynn was the pioneer of “telemedicine” in Australia. In addition to a pedal wireless one needed a specially designed medicine chest and an aeroplane.  In the past my unit provided quite sophisticated remote management of patients by means of the Steam telephone and close liaison with the patient’s GP and pharmacist. It was very time consuming, a small point often overlooked by “telemedicine” enthusiasts.  The only financial reward was the occasional bottle of scotch at Christmas from an extremely grateful patient.  In that  era the flying doctor’s radio skeds would have given the privacy commissioner a panic attack.  Yes, a huge amount of relevant information can be transmitted in digital format without high speed broadband. (e.g. check out RDT”s “Tempus Pro).  Necessity as the mother of invention driving “middle out” gentle evolution is clearly the way to continue the process started by John Flynn. If we can just keep the technology-obsessed, the self-promoting politicians, rule-bound bureaucrats and plaintiff lawyers at bay all should be well.

  4. David Noble says:

    A recent study by Deloitte Access Economics on the Benefits of High-Speed Broadband for Australian Households estimated that the financial benefit per household, by 2020, would be $3,800 per year with about $217 in savings from travel in eHealth, eGovernment and eEducation.  The Grattan Institute identified the unconstrained increase in healthcare expenditure as “the single greatest threat to national prosperity”.  It seems that “e-anything” is a positive step towards a financially stable country.  Even more pressing now the mining boom is on the slide. 

    As the custodians of the medical profession it is our responsibility to create the healthcare system that will serve the community into the future.  Either we do it ourselves or we let the politicians do it. 

  5. Greg Hockings says:

    I am interested in telehealth, as I have a number of patients from rural locations who travel considerable distances to consult with me, but what has deterred me from introducing it into my private practice so far is the associated bureaucracy.

    For example, a colleague who did a follow-up telehealth consultation was subsequently informed by Medicare that she would not be paid for the consultation, as the geographic boundaries used to define when telehealth was available had been changed and this patient was therefore no longer eligible to access telehealth under Medicare.

    In addition, I am not prepared to bulk-bill in private practice under any circumstances.  Your comment on “generous incentives” and “Medicare rebates” should be qualified, as bulk-biling is currently mandatory for Medicare payment of telehealth consultations.  The previous Fedeal government has been actively trying to increase bulk billing by specialists; for example, I know of an MRI scanner in a large regional town which was only granted a licence for Medicare patients on the condition that all MRI examinations were bulk-billed.

    Until I can continue my usual practice of billing patients at the time of consultation and then having them claim their rebate from Medicare, I do not intend to have any involvement in telemedicine.

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