Telemedicine across the ages

The “tyranny of distance” presents significant challenges for the Australian health industry, and is often a central reason for inequity of access to specialist services in rural and regional communities.

The health care choices for patients in these areas are usually limited, particularly for patients with prolonged acute or chronic illnesses. The problems are amplified when communities are widely dispersed, and Queensland is a classic example. Queensland, the second largest state in Australia, spans about 1600 km from east to west and 2400 km from north to south. More than two-thirds of Queensland’s 4.2 million people live in the south-eastern “corner” of the state, about 18% (770 000) live in major towns along the east coast, and 15% (650 000) are widely dispersed in remote townships.1 Many smaller towns developed around rural properties, mine sites or Indigenous communities.

Patients from rural and regional areas usually have no choice but to travel, and this generally means an inconvenient and costly journey far away from home, often with an end result of a 5- or 10-minute specialist appointment. Alternatively, specialists or specialist teams may travel to regional centres for outreach clinics. These visits are usually short (1 or 2 days) and intermittent, and involve the sacrifice of valuable clinician time during transit to and from the regional centres.

For many years, there has been much promise for the widespread use of telemedicine (the delivery of health services across a distance using communication methods such as videoconferencing and email) to support patients, especially in remote areas. The opportunities and benefits of telemedicine have been researched and discussed previously.2,3 Logical reasons for conducting telemedicine include the large distances involved and centralisation of specialist services in major cities. However, the uptake of telemedicine has been disappointingly slow.

In our experience, once the appropriate infrastructure is established, the success of telemedicine depends on the administrative and clinical systems supporting it. Attention must be given to scheduling, clinician and patient preparation, ease of access to telemedicine facilities, and sharing of clinical data and reports between sites.

It is important to consider the incentives for clinicians to participate in telemedicine. The conventional method of patient referral to a specialist is well entrenched and highly efficient for clinicians, with the cost and inconvenience of travel borne by patients or their families. When the distances are large, the health service may assume responsibility for patients’ travel costs, which may be substantial. Queensland Health provides funding of about $30 million per year towards the Patient Travel Subsidy Scheme (PTSS).4 This scheme has an important role in helping offset some of the costs associated with travel to see a specialist. But because the PTSS is well established and relatively easy to use, we believe that clinicians are more likely to choose this option than to opt for telemedicine. Without an incentive for clinicians to conduct telemedicine, this will probably remain the prevalent model.

For almost 10 years, we have shown the feasibility, clinical benefits and economics of a unique telemedicine service model, specifically in the area of paediatrics. More recently, some of the relevant principles of this telepaediatric service model have been applied to telemedicine in the field of geriatrics. Here, we provide an overview of our experience and recommendations.

In November 2000, we commenced a trial to determine whether we could encourage regional clinicians to use telemedicine instead of referring patients to specialists in the traditional way. A telepaediatric model was crafted by the University of Queensland’s Centre for Online Health (COH) in close collaboration with the Royal Children’s Hospital (RCH) in Brisbane.5,6

The telepaediatric service is configured around a centralised referral centre based in Brisbane, with selected regional centres across Queensland. If a specialist consultation is required, the referring clinician calls a toll-free telephone number, which links them to a telepaediatric coordinator. Once a referral is made to the service, a specialist response is guaranteed within 24 hours.7

The telepaediatric service is a clinical support program that directly benefits children, their families and the clinicians delivering services. Since the service began, over 7000 consultations have been conducted for thousands of children in Queensland, many of whom may have otherwise travelled hundreds or thousands of kilometres to see a paediatric specialist in Brisbane.

The COH currently delivers telepaediatric services to 82 regional hospitals in Queensland and several health centres in northern New South Wales (Box 1). A range of communication methods are used, including email, telephone and videoconference. About 90% of telepaediatric referrals result in a videoconference consultation (Box 2 and Box 3). Most videoconferences are conducted using systems owned and managed by Queensland Health, of which there are about 500 available statewide. Other sessions require dedicated videoconference systems installed by the COH, including mobile units (see below). Some telepaediatric consultations have also required videoconference links to specialists in Western Australia, Tasmania and the Northern Territory.

Since the service began, much of the work coordinated through the centre has become routine, with a broad range of clinics now scheduled 12 months in advance. The telepaediatric service, now a specialist outpatient department at the RCH, delivers all of its services online.

The telepaediatric service covers 37 different subspecialist areas and involves more than 240 medical, nursing and allied health staff. Subspecialist services offered by the telepaediatric service include cardiology, dermatology, diabetes, general paediatrics, neurology, oncology, orthopaedics, post-acute burns care, psychiatry, and surgery.8,9

The success of the telepaediatric network of services in Queensland spawned our research and development agenda at the other extreme of the life cycle, in geriatric medicine. There are almost no geriatric specialists practising outside of the south-eastern corner of Queensland — of about 30 geriatricians in Queensland, only three operate outside of the south-eastern corner, all in Cairns.

Geriatricians play an important role in hospital geriatric and rehabilitation units; they consult in ambulatory settings in the areas of cognitive impairment, falls and other geriatric syndromes; and they work with multidisciplinary teams to support assessment and care planning of older people with complex medical, functional and psychosocial problems.

Older people are more likely to have chronic illnesses, potentially requiring repeated visits to specialists. Their illnesses are often accompanied by disability, a further impediment to travel. When in hospital, transfer to a city specialist for consultation is impractical. This combination of factors creates considerable inequity of access to specialists for frail older patients.

Our research and development program in telegeriatrics commenced in 2005. A series of demonstrations was used to establish technical specifications and operational protocols to support inpatient and outpatient consultation, and geriatrician interaction with multidisciplinary teams.

There are special challenges for older people in using video-consultation. Many patients have impaired vision, hearing or cognitive function, although this is also a problem with “live” consultation. In our experience, older patients interact well, usually taking only a few seconds to engage in conversation:

A minority of patients, usually those with significant hearing impairments, require a person at the bedside to repeat the conversation.

The primary mode of telemedicine utilised is videoconferencing (Box 6). The protocol for preparing sessions imitates that used in telepaediatrics. An enhancement is the development and use of web-based standardised assessments, which enable records to be reviewed and progress notes recorded at both the clinical and distal locations. This substantially reduces the need for duplicate records and faxing of documents before consultation.

Numerous telegeriatric demonstrations are now in operation (Box 7), including a memory disorders clinic serving patients in north-western Queensland; geriatrician support to multidisciplinary case conferences in Rockhampton (Aged Care Assessment Team and an inpatient rehabilitation service at a private hospital); and transition care and a full ward service to a geriatrics and rehabilitation ward in Toowoomba. In addition, systems to support standardised geriatric consultations online have been established in two hospitals. Many aspects of these services have been subject to evaluation, with a focus on stakeholder acceptance, reliability of clinical decisions, cost and sustainability. Assessment of cognitive function appears particularly amenable to videoconference assessment.15,16

A needs assessment of geriatric services and the associated geriatrician workforce (or lack of it) has recently been completed. This will provide a template for expansion of the service models across Queensland.

This article presents an overview of our experience with telepaediatrics and telegeriatrics. Further effort is required to explore the potential of our approach in all other medical disciplines, including adult outpatient services, where there is likely to be high clinical demand and commensurate potential for savings.

A major challenge for sustainable telemedicine programs is related to funding. Generally, government funding supports the purchase and maintenance of telemedicine infrastructure, which leaves little or no investment towards the operation costs of managing the service and formal evaluation. Apart from telepsychiatry, videoconference activities tend to operate within the public health sector. If this method of health care is to be propagated, it should be acknowledged as a Medicare fee-for-service schedule item. Unfortunately, there are numerous examples of telemedicine failures around the world where large telemedicine networks have been constructed, but underutilised. Our suggestions for developing a telemedicine service are summarised in Box 8.

Telemedicine provides enormous potential to improve equity of access to health services in a cost-effective manner. To be successful, the focus must move beyond simply the provision of equipment and connectivity. Telemedicine services should be easily accessible, present no hindrance to the clinician, and should complement conventional outpatient services. Clinical processes may need to be re-engineered to ensure effective engagement of clinicians and efficient use of equipment. Attention must be paid to communication of clinical information, preferably in electronic format, to increase reliability and avoid wasteful duplication. We believe that our approach to telemedicine represents a serious attempt to meet these aspirations.

1 Scope of telepaediatric services in Queensland

2 Telepaediatric session with neurologist — standard videoconference

4 The first robot system was used in the paediatric ward at Gladstone Hospital to deliver specialist support

5 Telepaediatric robot consultations may be done directly at the bedside

6 A geriatrician performing a videoconference ward round

7 Scope of telegeriatric services delivered from Brisbane