Quality infrastructure, public and private sector collaboration, and funding models that take into account the various modalities of delivering healthcare, are necessary precursors to the successful implementation and adoption of telehealth-enabled models of care across Australia, according to technology entrepreneurs, healthcare workers, and public sector officials.
Dr James Freeman, founder of HCF-backed telehealth startup GP2U, says telehealth-enabled models of care are logical given the discrepancy between the distribution of doctors and distribution of patients across Australia.
"In the city, there's a one GP per 1,000 patients ratio. In the country, it's one GP per 3,000 patients or thereabout. If you look at specialists, then the numbers are far worse. There are less [sic] GP services available in the country and there are vastly less specialists, so we've got a problem. It means there is healthcare access inequality," he said.
"If you think logically about it, it shouldn't matter whether a patient accesses a health service using feet, wheels, or wings as the transport mechanism or video conferencing. If there's no extra cash component, then there's no reason for doctors to overservice or try to rort the system. It's just a different way of delivering the same services we're delivering now, but in a more patient-centric, convenient way."
A 2016 report by the Australian Institute of Health and Welfare said total expenditure on health -- recurrent and capital expenditure combined -- had grown each year from AU$95 billion in 2003-04 to an estimated AU$155 billion in 2013-14.
One in Four Lives, an industry initiative developed by organisations including the AIIA, Medibank Private, Philips, and the University of Western Sydney, believes healthcare costs will consume more than 100 percent of the entire revenue collected by the states by 2046, according to its One in Four Lives: The Future of Telehealth in Australia report [PDF].
"A 'perfect storm' of an ageing health workforce, the rising incidence of chronic conditions, and increased expectations of both consumers and healthcare professionals is contributing to unprecedented demand on our health system," the report says.
The general consensus is that telehealth, even if it requires significant initial monetary outlays, would help alleviate pressures on the healthcare system in Australia in the long-term, improve patient experience, and contribute to better health outcomes.
However, the Australian government cannot drive the telehealth agenda forward on its own, Freeman said.
"Government's role is to present the big picture of where they want the country to go, put in place core infrastructure that private enterprise can't afford to fund, put in place incentives, then let the private sector handle the rest," Freeman said.
"Private enterprise does things more efficiently than government, faster than government, and does it because government is so wrapped up in red tape and risk-aversity. A private company can see things that would be considered far too risky to do within public service."
Expanding funding, incentives, and eligibility criteria
In the One in Four Lives: The Future of Telehealth report, creating sustainable, profitable business models that can meet the needs of governments, service providers, clinical practice, and patients was singled out as "the real challenge" in telehealth today.
Financial disincentives created by the Medicare Benefits Schedule (MBS) are discouraging healthcare practitioners from using telehealth solutions in situations where it would provide considerable benefits to both practitioners and patients, NSW Health acknowledged in Telehealth Framework and Implementation Strategy 2016-2021 [PDF]. There is also uncertainty around whether Activity Based Funding (ABF), which is provided to hospitals, covers services delivered via telehealth, the report states.
Under MBS' eligibility criteria, funding for services delivered via telehealth will only be provided to specialist doctors and for consultations with patients living outside metropolitan areas -- the patient also needs to be at least 15 kilometres away from the closest practice.
General practitioners, allied health professionals, and nurses cannot bill Medicare for services delivered via telehealth, nor can clinicians consulting on a case via telehealth without the patient present.
This means that of the 140 million GP services that are delivered every year, none are telehealth eligible, and out of 160 million medical consultations conducted every year, just 6 million are telehealth eligible, Freeman said.
He added that given medical businesses are almost entirely dependent on government funding, telehealth-enabled models of care won't take off in any meaningful way until funding is guaranteed.
"Only 4 percent of the entire volume of medical services that are conducted in Australia today can get any Medicare funding for them. That's why the adoption has been so small -- it was either private pay or go and see someone face to face," Freeman said. "While patients might want the service for the convenience, if doctors aren't delivering it because they can't get paid for it, telehealth services won't work at scale."
According to Freeman, telehealth in Australia has suffered from "a lack of coherent vision" and "mismanagement".
"The idea is great, but the funding models that have been put in place to support telehealth implementation have been tragic," Freeman said.
"For example, if you look at skin cancer, [it is] incredibly common. Two out of three Australians will get skin cancer. One of the implementations for telehealth is just simple store and forward like we do for X-rays.
"I, as a GP, can take a dermoscopic image of skin cancer and I can send it to an expert who can then diagnose it and come back with a report. It's low-bandwidth, not real-time. Store and forward would work really well no matter what the infrastructure. Is there a funding model for it? Nope."
Rob Read, CEO of Australian Securities Exchange-listed medication management startup MedAdvisor, said there are patient populations willing to privately pay for telehealth services for the convenience, but agreed the uptake of telehealth would be more widespread if funding was guaranteed for healthcare practitioners.
"Our whole health system has been set up around acute care -- for example, someone breaks their leg and they have to come in and be treated. Whereas there are people with chronic diseases who need to be managed over time. They might not require lots of face-to-face time, but [caring for them] might involve monitoring, seeing stats, seeing adherence, and a slightly different engagement with doctors," Read said.
"I think that's the shift that Medicare will need to make in time to facilitate telehealth and these sorts of convenience-based services, to redeploy some of the money and time into where it's getting better return on effort for the government and return on investment as well."
The Australian government is looking to reduce reduce administrative appointments, Read noted, where patients come in for specialist referrals or repeat prescriptions for medications they've been on for years. Each of those administrative appointments is costing the government AU$37. Therefore, the funding can be reduced by building new technologies -- or standardising existing ones -- that can achieve the same outcome, Read said.
"I think for repeat prescriptions and specialist referrals, there should be a standard Medicare item number and it shouldn't matter whether you're face to face or doing it via telehealth. Let's say instead of being the AU$37 Item 23 which it is today, it could be a AU$15 Medicare reimbursement or a AU$10 Medicare reimbursement just for that purpose," Read said.
"A lot of doctors get put under a fair bit of pressure by patients to just give them repeat prescriptions without having to sit in so they're doing all this extra work for no reimbursement. If there was some Medicare item number, then that would support the adoption of telehealth programs."
Read said medication management solutions can deliver efficiency gains to both patients and doctors. By significantly reducing or eliminating administrative appointments altogether, there is less congestion in waiting rooms, and more time to focus on patients that require face-to-face engagement.
"They can [do the prescriptions and specialist referrals] at home or at a time that suits them, like when they don't have people in the waiting room. They can much more efficiently manage their day and spend time on the people that need it the most. The doctor's business case is pretty strong," Read said.
"They do feel at times concerned that if lots of people are taking up telehealth for repeat prescription services, then they're missing out on their consults and therefore missing out on revenue.
"But a lot of doctors have full waiting rooms and it's hard for people to get appointments when they want. In that regard, there's an opportunity for those that are busy to make it much more efficient and for those that aren't busy to really grow their business using technology."
In addition, Read said one in two people provide inaccurate medication information when they've been admitted into hospital, requiring hospital staff to have to go through a manual medicine reconciliation process where they call up pharmacies, GPs, and specialists.
He added that it would be easier if, for example, hospitals could retrieve -- with the patient's permission -- medication lists directly from an electronic profile. It would also help reduce hospital readmissions related to medication misadventure, Read said.
"In the over-65 age group, something like 25-30 percent of hospital readmissions are related to medication misadventure and it often happens within 28 days after discharge. This is because typically you've got a new medication regime, you've been in hospital which is a fairly stressful situation, and you've had a quick briefing on your new medication regime that's potentially gone in one ear and out the other," Read said.
"If we could provide that information on a tablet, on a phone, on the internet, just make it really easy for patients, they can refer back to it. They can find out more about their medication, when and how they should or shouldn't be taking it, such as with or without food."
For such a system to work in full capacity, it would require the introduction of electronic prescriptions, Read admitted.
"One area the government is keen to look at is electronic prescriptions, because in Australia you have to have a physical paper script. A lot of other markets have electronic prescribing and it's like an airline ticket. You can choose to print it out if you want, but if not, it's on the app ... I think having electronic prescriptions that is recognised as a legal record for a prescription would reduce effort and cost in the system," he said.
Updates to MBS funding models are yet to come to fruition. However, state health departments across Australia such as NSW Health, VicHealth, and Queensland Health are aware of the issue and are working to expand telehealth funding streams for GPs, nurses, and allied health professionals, as well as to recognise telehealth activity in metropolitan areas.
"I know that the federal government is doing work on this, but the challenge is how we change those funding models so that it's more about the outcomes being achieved such as a patient finishing a cardiac rehabilitation program, whether virtually or in the clinic, which supports the patient in their behaviour change to reduce the likelihood of a second heart attack," said Dr David Hansen, CEO of the Australian eHealth Research Centre, a joint venture between the Commonwealth Scientific and Industrial Research Organisation (CSIRO) and Queensland Health.
"We're starting to see those reimbursement models taking into account the different modalities of delivering health services ... so reimbursements for services no matter how they're delivered, which achieve a certain outcome."
Freeman said another benefit of telehealth is that it can introduce market forces into an uncontrolled market.
"At the moment, for me to go visit a dermatologist in Hobart, it will cost me between AU$200 and AU$300, and I'll get about AU$70 back from Medicare. That's because there are only a few of them so they can charge what they want. If I want to go see a psychiatrist, all but one won't bulk bill. They will all charge an out-of-pocket fee," Freeman said.
"Whereas I could get you a dermatologist appointment tomorrow online and it'll be bulk billed. There are hundreds of dermatologists in Brisbane that are happy to see people for the scheduled fee so you can get a dermatology consult online for AU$70.
"Private insurance can't cover what the doctor wants to charge, but you can introduce competition and price transparency which will be a great benefit for the health system."
Infrastructure, interoperability, and centralised data
In January, the Australian Medical Association (AMA) called for "urgent" government action to ensure Australians living in rural, regional, and remote areas have access to affordable and reliable high-speed broadband and the healthcare services it can enable.
Subpar internet connectivity and an absence of policies around equitable and affordable access to telecommunications are significant barriers for remote Australians seeking healthcare, the AMA argued in its Better Access to High Speed Broadband for Rural and Remote Health Care report [PDF].
Many rural and regional areas have poor electrical and network connectivity, with relatively small download allowances, and at a higher cost and slower speed than the services available in metropolitan cities.
However, improvements in technology means distance should no longer be a barrier, the AMA said. There is a range of inexpensive and free web-based video conferencing solutions that can be used for consultations with healthcare practitioners. Broadband and 4G internet is widely available in metropolitan cities and some parts have access to the National Broadband Network (NBN).
In January, the state government of Western Australia announced the establishment of a AU$22 million telecommunications fund to improve infrastructure in the state's rural and regional areas, mainly so that agribusinesses can leverage improved mobile and internet coverage, knowledge management systems, wireless technologies, and computer-aided or controlled devices to help drive the future economy of regional Western Australia. However, the infrastructure that's put in place will also support the delivery of telehealth, which is already on the cusp of mainstream adoption, according to WA Health.
Freeman said even in metropolitan cities, the underlying infrastructure of Australia's internet has only just caught up to where the UK was over a decade ago.
"I had 10Mbps 15 years ago in the UK," Freeman said. "A video conference from Hobart to Sydney is often more fraught than one from Hobart to Tokyo or Hobart to LA just because the infrastructure we have is really dreadful."
"It's a pity because good internet infrastructure is going to be a key economic advantage, just like roads and ports were a century ago."
When it comes to infrastructure that supports the delivery of telehealth -- particularly via videoconferencing -- Western Australia and Queensland are considered to be leading the way in Australia, according to a report [PDF] by the NSW Ministry of Health.
"The geography of those two states have meant that they have forged ahead with telehealth-type models of care, particularly videoconferencing. They've put in a lot of infrastructure around that," Hansen said. "But NSW is also looking at a range of initiatives to virtualise how they provide health services."
In Western Australia, the Emergency Telehealth Service provides specialist emergency medicine support to clinical staff treating acute patients in country hospital emergency departments, as well as outpatient consultations between Perth-based specialists and regionally-based patients via videoconferencing.
There has also been considerable investment in infrastructure -- particularly, a videoconferencing network -- in Queensland, with Queensland Health managing more than 2,000 telehealth systems across the state including 650-plus videoconferencing systems. Telehealth is mainly being used by public hospitals, community health centres, Aboriginal Medical Services, and the Royal Flying Doctor Service.
However, other state governments are also cognisant of the potential benefits of telehealth. In March, for example, the Victorian government announced that it is distributing AU$5 million across 15 telehealth projects to better connect patients in regional and rural areas to a range of medical specialists across the state.
Currently, the NSW government's Agency for Clinical Innovation (ACI) is working with the Multidisciplinary Pain Management Clinic to deliver telehealth-based services to chronic pain patients across NSW. Telehealth is currently available in a dozen of the 21 pain clinics, with two on the waiting list for implementation.
"If you are a patient with chronic pain, travelling, regardless of how long it is, is not ideal. A lot of our metropolitan clinics have reported they're more likely to see cancellations of appointments because patients have what they call 'a bad pain day'," said Julia Martinovich, manager of telehealth at ACI. "By offering them another way of accessing the services -- patients can receive [healthcare services] in the comfort of their home -- it's a means to improving patient experience."
"GPs love it too. We've also noticed an increase in repeat referrals to use the service. They might have another patient within their GP practice who they think could benefit from the service so they're more likely to re-refer."
Martinovich also pointed out that telehealth can support shared education, professional development, and better networking among healthcare practitioners.
"I know when I was a clinician, even though I was based in Sydney, trying to travel to events was difficult so having video conferencing could help with that," Martinovich said. "It could also be a means to connect -- particularly, with complex cases where other government jurisdictions are involved -- educational, family, and community services ... to bring people together quickly and immediately."
Martinovich said the implementation of telehealth has been well-received by multidisciplinary pain clinicians. She noted though that there is always going to be a reaction to change -- positive or negative -- and so an effective change management process needs to be implemented.
ACI, for example, developed a chronic pain telehealth toolkit that steps clinicians through the process differences between delivering healthcare in person and via videoconferencing. The NSW telehealth guidelines also assist with the change process.
"The toolkit itself doesn't bring about the change. Ongoing implementation support and coaching has assisted sites with adoption of this change in practice. This involves site visits, mock sessions, and modelling/role playing troubleshooting techniques," Martinovich said.
"We really desensitised our clinicians [to the technology]. We didn't say 'Here's the technology, see you later'. We really worked with our clinicians to bring them across the change."
The agency also received funding from NSW Health for investment in a full-time digital health project officer for 18 months to help roll out HealthDirect's Video Call solution across the state.
Martinovich also stressed the importance of not designing models of care around the technology available, as well as having clinicians and consumers involved in the planning and design process.
"ACI recommends designing care models first and documenting workflows for that model, then finding technologies to fit that model as opposed to designing models around technology," she said.
The argument for this approach is also presented in the Strategic Review of Telehealth in NSW report [PDF] which states that telehealth-enabled models of care should be driven by a specific clinical need or issue, rather than 'just because'. A purpose-driven model ensures the technology that is implemented actually delivers what is required -- and subsequently is less likely to be abandoned by users.
The need for government to facilitate interoperability of systems and devices was also presented in the report. Interoperability would enable easier communication and collaboration between, for example, healthcare practitioners in different state jurisdictions.
"If you look at the concept of secure messaging, how did we end up with seven secure messaging service providers all running on what's effectively different rail gauges? It's a bit like building a railway system, but none of the gauges line up," Freeman said. "Secure messaging is fantastic, but everybody's got to be able to talk to everybody, so we need a standard format."
He also noted the value of centralising the data collected from a variety of telehealth services. Those datasets, when combined, would provide actionable insights about the healthcare system.
"With the personally controlled My Health Record, it should have been opt-out rather than opt-in -- like tax file numbers. If you want to opt out you can, you can make yours private, but it's still going to be there. Then we could have done something useful with it, which would be push all the data from pathology into it," Freeman said.
"Pathology is a AU$5 billion a year industry, but about 20 percent of all [tests] are repeated by another GP within 60 days of the first GP ordering them. The reason for that is I, as a doctor, can order a test in about 20 seconds, whereas ringing up a single pathology company will take me at least a couple of minutes. Ringing up three or four, if you don't know where the results are, will take me the best part of the entire consultation.
"If we put all of the data into the mandatory My Health Record, then all you've got to solve is the single biggest problem with eHealth which is how we determine who should have access to this data. The upside of it is you potentially save AU$1 billion a year in pathology tests that are repeated unnecessarily."
Beyond videoconferencing to deliver healthcare
Hansen said that while telehealth has traditionally been seen as videoconferencing between a patient and healthcare practitioner -- CSIRO Data61 developed a real-time video communication platform, Coviu, to connect healthcare practitioners and patients through web browsers and allow them to live-share medical data and images -- the organisation views telehealth as encompassing a range of technologies to deliver healthcare.
"At CSIRO, we take a broad definition of telehealth -- it's not just about videoconferencing, it's about how we deliver health services to people in the community in their homes or even from their office so they don't have to travel to the doctor's office, the clinic, or the hospital," Hansen said. "It does include more than just traditional videoconferencing; it stems out to different forms of telehealth -- store and forward for imaging and screening, mobile health, home monitoring through various mechanisms."
A few years ago, CSIRO ran a teleophthalmology trial in the Torres Strait Islands and Western Australian goldfields where nurses were trained to take retinal images on site using a mobile device. Those images were then forwarded for reading by ophthalmologists in Perth or Brisbane.
"That meant that we could actually provide ophthalmic screening to, in particular, diabetes patients in the community without the doctor having to travel to them or them having to travel to the doctor. That provided screening to a lot of people who wouldn't normally be screened," Hansen said.
"Through that study, we were able to diagnose people with diabetes who didn't even realise they had it. There were some people who had really bad diabetic retinopathy who needed to be urgently seen for sight-saving treatment.
"Our teleophthalmology work, which has now gone into other areas like wound care, is currently run by our group in Perth."
Given nearly 50 percent of Australians suffer from chronic diseases such as cancer, mental illness, and diabetes, according to CSIRO, the organisation also ran a national telemonitoring trial of patients with chronic illnesses who had two or more unplanned hospitalisations in the prior 12 months.
The 18-month trial was performed across six sites in Tasmania, Victoria, Canberra, Sydney, and Queensland, where more than 280 elderly patients were provided with telehealth devices that measured their heart rate, spirometry, blood pressure, oxygen levels, lung volume, body weight, body temperature, and other biometric information. This was then transferred to care coordinators for assessment and intervention where needed.
The telemonitoring trial showed a 24 percent saving on MBS expenditure over 12 months. This was achieved through reduced GP and specialist visits and procedures carried out. The mortality rate was also reduced by 40 percent.
"Our research showed the return on investment of a telemonitoring initiative on a national scale would be in the order of five to one by reducing demand on hospital inpatient and outpatient services, reduced visits to GPs, reduced visits from community nurses, and an overall reduced demand on increasingly scarce clinical resources. This could equate to savings in the order of AU$3 billion per annum to Australia's healthcare system," CSIRO stated in a report.
In 2012, CSIRO completed a randomised control trial of mobile phone-based intervention in Brisbane for cardiac rehabilitation. Those who survive heart attacks need to be managed over time -- now more than AU$5.5 billion is spent every year on the management of heart disease in Australia, according to CSIRO. Added to that, the participation rate in cardiac rehabilitation programs is poor.
CSIRO's Care Assessment Platform (CAP) program was designed to deliver cardiac rehabilitation via smartphones for patients and via a web-portal for clinicians. Instead of patients having to travel to hospital or the outpatient clinic every week for six weeks to complete the National Heart Foundation's cardiac rehabilitation program, they were able to be treated remotely.
Data such as blood pressure, weight, physical activity, and other biometric information was collected through the smartphone every day and uploaded to the web portal for clinicians to review. The patients also had a weekly phone call with their clinicians who mentored them through the themed program.
Cardiac patients who used CAP were nearly 30 percent more likely to take part in a cardiac rehabilitation program than those who had to travel to the hospital or outpatient clinic, and were nearly 70 percent more likely to complete the program.
"[The trial] also triggered a whole heap of other mobile health trials in other areas where health services require people to go back into hospital, normally outpatient services, which we think could be replaced through a mobile phone-based approach," Hansen said.
A company called Cardihab took CSIRO's technology and made it available as a commercial service.
Across the ditch
In New Zealand, it has been estimated that the benefits from broadband-enabled health care could reach about NZ$6 billion [PDF] over a period of 20 years from reduced hospital, travel, and drug costs, and improvements in health care. This is one of the reasons the New Zealand government decided to invest in telehealth.
In June 2015, teletriage organisation Homecare Medical was awarded a NZ$257 million national tender to combine New Zealand's existing helplines into one integrated national telehealth service, providing 24/7 assessment and advice on medical emergencies, poison ingestion, quitting smoking, alcohol and drug addiction, immunisation, depression, and gambling, in addition to after-hours teletriage services for 600 general practices.
All of Homecare Medical's services -- which is run in partnership with the Ministry of Health with support from the Accident Compensation Corporation and the Health Promotion Agency -- are delivered free of charge to New Zealanders.
Across a period of 10 years, the organisation has the responsibility of reducing acute and unplanned care, supporting citizens in need of access to care, as well as improving self-care and health literacy. Homecare Medical is also required to innovate over the decade to meet the changing needs of consumers and technology.
As of November 2016, Homecare Medical claimed that it helped around 425,000 New Zealanders who contacted the service more than 550,000 times.
"Our job is to really bring technology-enabled healthcare at scale across New Zealand, to strengthen the existing health system as opposed to disrupting it from the outside," said Andrew Slater, CEO of Homecare Medical.
"As a country, we're still working out how we virtualise primary care -- from a patient to their GP -- and we've seen some pilots in that space over the last 12 months. What's critical in that environment is making sure that the virtualisation of primary care does not lessen the health outcomes that you see with the enrolled healthcare model that we have in New Zealand."
Slater said the New Zealand government has provided a great platform to deliver telehealth-enabled models of care, which hasn't been provided in Australia and many other countries.
"For example, we've got one provider across all domains of healthcare for the next 10 years and so we've got funding certainty," Slater said. "Homecare Medical operates under the Public Services Act, so we get to use all the goodness of government in delivering that service over the next 10 years. We've got a mandate for innovation. I always say if we're doing what we're doing today in 10 years' time, then we've failed to innovate."
Slater believes one of the biggest challenges for healthcare systems globally -- as greater time, money, and effort is put into virtualising healthcare -- is ensuring that telehealth services are aligned with existing systems.
"The challenge for health systems globally is that we see [virtual healthcare] as an enabler across the existing silos of the health system," Slater said. "The last thing we want to do is to create a virtual healthcare ecosystem that becomes disjointed from the existing systems."