Beyond the EHR: telehealth technologies in Australia

Recently in Voice+Data we looked at the plans for Australia’s national e-health network and, in particular, the politics that have delayed its introduction. This month Andrew Collins takes a look at the actual technologies involved, the benefit they bring to remote areas and obstacles to their adoption. There is hope but there is a long way to go.

Australia is in the process of developing an e-health network - a system that would connect the disparate stockpiles of digital patient records that exist in hospitals and clinics around the country. The completed network is hoped to allow patients to move through the nation’s health system more easily, ease administrative burdens on hospitals, smooth the prescription process, lower healthcare costs and more.

But the network will also act as the foundation for a more complex set of technologies that promise to improve the delivery of health services to remote regions. Many of these technologies are already in use around the nation.

Tests and trials

Terry Percival, Lab Director at NICTA, has some insight into the telehealth trials going on around the country.

Percival coordinates NICTA’s involvement with ACBI (Australian Centre for Broadband Innovation) - a collaboration between NICTA, CSIRO and the NSW Government, which exists to investigate and demonstrate broadband-based applications. ACBI is currently running trials in the early NBN release sites, trying out broadband applications, including e-health .

Percival is no stranger to telehealth. In 2003, he was part of a team in NSW that set up the Virtual Critical Care Unit (ViCCU), a system that allowed specialists in one city hospital to oversee and direct a team of doctors and nurses treating a patient at another, smaller, geographically distant clinic. The system used advanced telepresence, with several high-quality video streams running over a 100 Mbps fibre link, to connect the clinics.

And while videoconferencing had previously been used for consultation between doctors, the ViCCU was the first system in the world with video quality and response time good enough for a doctor to officially assess and treat a patient over a remote videoconferencing link.

Most remote e-health applications follow a similar theme: connecting local doctors and nurses with remote specialists. It maximises doctors’ time, saves money, gets expertise where it otherwise couldn’t reach and allows for quicker diagnoses, potentially saving lives.

And this theme is filtering into many fields of medicine.

“We did some trials but other people have taken up a lot of these sort of ideas,” Percival says.

One CSIRO trial in the Pilbara region involves diagnosing diseases of the retina, he explains. Optometrists and nurses take high-quality photos of the inside of a patient’s eyes, which are sent over a broadband link to a remote ophthalmologist or radiologist, who then looks for the presence of disease in the image.

Elsewhere, teleradiology trials are taking place. Typically in hospitals, digital X-rays are taken of accident victims when they present at an ER. In these teleradiology trials, the X-rays are then sent to a radiologist in another clinic, who can advise whether urgent treatment is necessary or if the patient can come back later.

Teleradiology gets more interesting when you consider the Australian-trained doctors who practice overseas. One company in the UK has these expat doctors working in the daytime over there - our night-time.

“So if you get an accident victim coming in late at night, you send the X-ray to the UK where it’s 10 o’clock in the morning. [These expats] are accredited in Australia - qualified Australian doctors. They can read it and make a diagnosis at 2 o’clock in the morning,” Percival says.

Barriers to change

But these trials are just that - trials. There are no standardised state- or hospital network-wide deployments of this technology. This is for a few reasons.

One basic problem is the simple lack of high-bandwidth links between clinics. Without these links, any attempt at videoconferencing results in low-quality video and laggy audio. Under these circumstances, doctors aren’t comfortable making diagnoses, or recommending treatment. Also, any imagery transfer is likely to be too slow to bother.

There are many vendors in this space, each with their own file formats and ways of transferring data. This creates problems if you want or need a multivendor environment.

Robert Stegwee, Principal Consultant for IT in Healthcare at Capgemini, says: “To actually enable different makes and vendors of the technology to work together within one network, you need interoperability standards.

“And not just interoperability - being able to get the data from one place to the other - but also ensuring correct interpretation; and in the case of images, correct rendering of images on remote screens, because it can be quite important to have the right rendering of the pictures and no distortion of the images,” Stegwee says.

Some vendors are playing nice when it comes to standardisation, particularly with homecare technologies - devices that sit in patient’s homes and take readings on measures like blood sugar, blood pressure, pulse, lung function, temperature and so on.

“Large players like Philips, GE, Intel and Microsoft are working together to develop standards for these home sensor systems,” Stegwee says.

But not all vendors are so keen to adhere to standards. Stegwee points at patient portals as an example.

“Large hospital information systems vendors will develop a portal that is integrated with their solution only and will not enable other solutions to be part of such a patient portal,” Stegwee says.

“Whereas if you look at the applications of e-health - especially in the homecare and remote sensing area - you need that variety of applications, and it’s not a hospital centric thing. So what you see happen is that patients are confronted with several portals that they have to log on to,” he says.

Percival also notes a lack of telehealth guidance from the powers that be. NSW Health, for example, is trying to implement a top-down approach, and has rolled out videoconferencing to all its hospitals and clinics, but “there’s not this systematic way of treating patients, or doing all these really exciting things”, he says.

“It would be good to set some national telehealth standards,” he says. “When you’re building a new hospital or a new wing, they should be setting aside rooms for virtual critical care, for teleconsultation, for telepsychiatry.

“I don’t think any health system in Australia has got a vision for what telehealth is going to look like in five years’ time,” Percival says.

The path forward

But for all of these obstacles, there are solutions brewing.

The NBN, in whatever form it ultimately takes, is hoped to help provide reliable, consistent high-bandwidth links between hospitals, to enable the more bandwidth-intensive e-health applications.

“The trick is we’ve got to make sure the NBN goes to all the right places,” Percival says.

The problem of convincing vendors to adopt a standards-based approach is not insurmountable, either. In many cases this will happen organically thanks to market pressure.

“There’s a clear indication - and that has been set by the market - that multivendor solutions are requested by the clients, the hospitals, the hospital systems or even the governments,” Stegwee says.

“They see it as a necessity for market entry to actually support these standards, because almost any tender that you see on e-health and health IT will have a chapter on which standards, and which part of the standards, need to be supported in order to be a viable entry in that tender,” he says.

Some vendors need convincing, however. Stegwee points to a group of vendors involved in e-prescription that required a three-year-long conversation before they were swayed to a standards-based approach. And that took some politicking - and incentivising.

Such incentivising can take several forms.

“One well-developed way of doing that, especially in these government-regulated instances, is to provide a financial incentive to the [healthcare] providers to install a system that’s compliant, and they will then get the money to commission these new systems with new capabilities from [vendors]. So there’s an indirect flow of money going through the providers to the vendors,” Stegwee says.

It also helps to establish communication with the vendors and use their experience to help shape the standards, so it’s actually feasible for them to make the changes.

Finally, Percival aims to help build support for a top-down approach by demonstrating the power of telehealth systems through ACBI, in the hope that doctors put pressure on their superiors to adopt the technology.

“That’s our role - to show people what’s possible and get them excited. Then they’ve got to push to do trials and get it into the health bureaucracy and convince them that it’s got to become more widespread,” he says.

Percival and his cohorts also target those in the decision-making political positions.

“When we can, we bring the politicians out to see demonstration units to give them a feeling of what’s possible,” he says.