The Brave New World of Health Communications

Advances in information and communication technologies bring changes to healthcare delivery for providers and consumers.

On average, only between 14 and 43 per cent of patients complete a cardiac rehabilitation program at hospitals or outpatient clinics after suffering a heart attack. One of the reasons for the dropout rate of patients from these rehabilitation programs is difficult access for those living in regional and rural Australia.
Today, technology is offering a potential lifeline to heart attack victims by increasing the accessibility and compliance rates of rehabilitation treatments.
The Australian e-Health Research Centre (AEHRC) has developed the Care Assessment Platform – a solution that uses smartphones, the Internet, and information and communication technology tools to enable patients to carry out post-heart attack rehabilitation in their own home.
Patients use a smartphone with customised software to measure and record data such as the amount of physical activity they do, their weight and blood pressure, and to record sleep quality, stress, meals and any tobacco and alcohol use. This data is synchronised daily to a web-portal, where it is closely monitored and assessed by healthcare providers.
Mobile phones are also used to facilitate regular video and/or teleconferences between patient and healthcare providers, so the health professional can discuss a patient’s results, adjust treatment as necessary, and encourage them to stick with the program.
Educational multimedia content and relaxation files are also stored on patients’ phones and can be accessed as and when needed, providing information for example on what a heart attack is. And patients receive daily motivational SMS messages that support their individual health goals and encourage ongoing adherence to the rehabilitation process.
“We used a mobile phone to deliver a cardiac rehabilitation service, rather than the patient having to come back to hospital twice a week for six weeks after their heart attack,” says Dr David Hansen, CEO of the AEHRC.
“These programs reduce the likelihood of a second heart attack, but only a small proportion of people complete a cardiac rehabilitation program,” he continues.
“A lot of that has to do with getting out of hospital, getting back into a normal life, going back to work…so getting to hospital or a clinic can be difficult. But this program that relied on a mobile phone saw double the uptake and adherence to rehabilitation.”
The AEHRC has also been
using leading-edge technology
and expertise to develop a high-fidelity colonoscopy simulator
for surgical simulation. The technology is currently being commercialised through a Swedish company, and allows clinicians
and nurse practitioners to
practise and achieve a high level
of competency and skill before
they carry out a colonoscopy on
a real patient.

BRIDGING GEOGRAPHICAL BARRIERS
Meanwhile, in Temora in the Riverina area of New South Wales, Dr Ash Collins, a GP and CEO of TeleMedicine Australia, is also leading the charge for Australia’s healthcare system to move into the 21st century. He defines telemedicine as “using information and communication technology (ICT) to provide medical care at
a distance.
“In 2011, the government announced support for telehealth consults at GP and specialist level and it announced some Medicare items for GPs and specialists to claim telehealth consultations,”
says Collins. “Since then we’ve
been providing telemedicine technology and solutions in
Australia to aged care and the primary healthcare sector.”
This includes operating a clinic with three GPs who offer telemedicine consultations to patients in the Riverina area. Collins and his colleagues have so far performed around 1500 telemedicine consults to remote and regional patients – eliminating the barrier of geographical distance. They have also connected their patients to around 270 medical specialists around the country – mostly endocrinologists and psychiatrists with patients needing follow-up consultations post-surgery.
“If someone has a hip or knee replacement, they no longer have to go back to Wagga Wagga to see their surgeon for a follow-up consultation. They come to our clinic, the GP uses ICT to connect
to the room of the surgeon and the GP does a physical examination on the patient for the surgeon, who then gives advice on management,” says Collins.

MANAGING DIABETES REMOTELY
Telemedicine Australia is also working with a number of GPs to treat patients with diabetes, linking them remotely to an endocrinologist in Sydney. The technology has had more than an 80 per cent success rate in getting diabetes patients’ HbA1c levels below seven – an indicator of how well a patient is controlling their glucose levels.
“The telemedicine results surprised endocrinologists and GPs, but patient feedback suggests that when a specialist is regularly involved with managing their diabetes it motivates them to more actively manage their lifestyle. They walk more, exercise more, watch what they eat more closely – all a major part of diabetes treatment.
“And with regular specialist feedback, we have better management around insulin adjustment. Insulin needs to be looked at every three to seven days but a patient from Temora would find it hard to see an endocrinologist in Wagga Wagga that often; it’s a 150-kilometre trip. With telemedicine, patients are in touch regularly with an endocrinologist without having to travel. GPs send the endocrinologist a text with a patient’s data, and the specialist replies with the required insulin adjustments.”
Such telemedicine initiatives also increase educational opportunities for rural practitioners, Collins notes. “We’ve been connected to more than 200 medical specialists and, in each consult, we receive practical advice which may not have been available in GP workshops.”

DEFINING HEALTH TECHNOLOGY
These are just a few current examples of how initiatives described variously as e-Health, telehealth, telemedicine, and information and communication technology are shifting the ways in which Australia’s healthcare is delivered.
The World Health Organisation defines e-Health as “the combined use of electronic communication and information technology in the health sector”. The government’s National E-Health Strategy defines it in more practical terms as “the means of ensuring that the right health information is provided to the right person at the right place and time in a secure, electronic form for the purpose of optimising the quality and efficiency of healthcare delivery. E-Health should be viewed as both the essential infrastructure underpinning information exchange between all participants in the Australian healthcare system and as a key enabler and driver of improved health outcomes for all Australians.”
Telemedicine is the harnessing of ICT to provide medical and healthcare at a distance, removing geographical and time barriers that can disrupt access to timely and efficient healthcare. Telehealth also relies on information and communication technologies to bring health providers and patients together. The Department of Health defines it as using telecommunication techniques to “provide telemedicine, medical education, and health education over a distance”.

FACING THE PERFECT STORM
While there may be some overlap in definitions and while technology is wide-ranging and diverse, all stakeholders involved in designing, delivering, managing and sustaining the nation’s healthcare system believes technology will play an increasingly critical role.
Gary Morgan, executive director of MPT Innovation Group in Queensland, is co-author of a research and discussion paper called One in Four Lives: The Future of Telehealth in Australia. He says the paper was an industry initiative to move the e-Health conversation forward, and beyond “projects and pilot programs”. One in Four Lives refers to a “perfect storm” of an ageing health workforce, the rising incidence of chronic conditions, and the increased expectations of consumers and healthcare professionals. Morgan adds that Treasury modelling predicts that, based on current trends, healthcare costs will consume more than 100 per cent of the entire revenue collected by states and territories by 2046.
“We face a rising tsunami,” he says. “This is my 15th year in telehealth and for all those years we’ve been talking about proof of concept, pilot projects… but when we look at what is happening in the National Health Service (NHS) in the UK and with Veterans Affairs in the USA, they are two of the world’s largest telehealth programs and they are not talking pilots and projects. They have demonstrated that they can change the way care is happening.”
In 2011, the US Department of Veterans Affairs telehealth program helped 50,000 Americans with chronic conditions such as heart failure, hypertension, diabetes and post-traumatic stress disorder. They were supplied with telemonitoring equipment and were put in touch with care coordinators who helped them maintain their health remotely, and reduce visits to hospital and hospital stays.
The NHS has rolled out a similar telemonitoring service for 3 million patients with experts hoping it will reduce utilisation of NHS healthcare resources by up to 56 per cent. Pilot programs also produced a significant 45 per cent fall in mortality rates.

VIRTUAL VISITS AND CONSULTATIONS
Closer to home, Morgan cites other examples of telehealth proving its potential and value. The Royal District Nursing Service (RDNS) telehealth project, Healthy, Happy and at Home, allows a nurse to make a virtual visit to a patient at home and won the Outstanding ICT Innovation Award in the Asia Pacific Eldercare Innovation
Awards 2013.
The seniors-friendly telehealth solution will potentially enable earlier hospital discharge for patients, prevent medicine mismanagement, and make better use of nursing resources. Each patient has a special monitor
with an in-built camera, allowing nurses at the RDNS call centre
to conduct two-way video calls with patients at home. The project is being pioneered with the help
of the Victorian Government
under its Broadband Enabled Innovation Program.
And the Queensland Telepaediatric Service (QTS) marked its 20,000th consultation in May 2014 when a Brisbane paediatric specialist visited, virtually, a two-year-old burns patient living in Rockhampton.
QTS has been connecting Brisbane medical specialists with children in regional and remote Queensland via virtual consultations for more than 14 years and is one of the largest paediatric telehealth services in the world. It relies on a blend of email, telephone and videoconferencing.
“Our mission has been to give patients in regional and remote locations convenient access to high-quality specialist health services, as close to home as possible,” says Dr Anthony Smith, deputy director of The University of Queensland’s Centre for Online Health. “QTS has been able to save thousands of families the physical and financial burden of a trip to Brisbane to see a medical specialist at a stressful and emotional time.”

OXYGEN OF CARE
Leif Hanlen is technology director at National ICT Australia (NICTA). In partnership with the Australian National University, University of Canberra, ACT Government and a number of other organisations, NICTA opened what it calls the ‘Living Laboratory’ in March 2014. Hanlen hopes the initiative will foster further innovations in e-Health.
“The objective is to bring together the end users, the decision-makers and the innovators to build a culture of co-design, co-deployment and co-delivery of service, and where the ICT is part of the oxygen of care. We want to remove the idea that somehow ICT is a crazy, wild future. Every clinician is using some form of electronic system and some form of ICT already,” says Hanlen.
The Living Laboratory is based in a community GP superclinic in northwest Canberra and is staffed by GPs and students on practical placements. It incorporates imaging, pharmacy, pathology, mental health, nursing, midwifery and physiotherapy, and brings together preventative care, outpatient care and community and in-home care.
“As the GPs and students deliver care we bring together small and medium enterprises that may have a technology solution and are looking for applications in health. We bring together developers and researchers to talk with clinicians so they can innovate together,” says Hanlen. “The long-term vision is that, as students become clinicians in the wider community, they are used to the idea of interacting with ICT and they interact with ICT developers regularly.”
Health has been one of the earliest adopters of ICT in Australia, Hanlen says, although the way in which it has permeated healthcare may not always be obvious. “You don’t walk in to a doctor’s surgery and see your doctor whip out a crazy electronic device – but the ICT is there in the background, just like the electricity cables are in the background in your house,” he says.
“ICT is the only feasible way we are going to see the scale of self-delivery increase without a corresponding increase in staff and costs. If there is not ICT involved in the delivery of a service then there is great difficulty getting that service to the widest population at a reasonable cost.”

ICT IN HOSPITALS
Highlighting how ICT is being used in hospitals, NICTA also collaborated with Alfred Health, Melbourne Health and the Peter MacCallum Cancer Institute in Victoria to develop a high-accuracy natural language technology system that can perform surveillance of fungal infections by automatically processing radiology reports.
Invasive fungal diseases (IFD) cause more than 1000 deaths in hospital and cost the Australian health system more than $100 million annually. The most common life-threatening fungal disease is aspergillosis, which is associated with a 33 to 75 per cent mortality rate. NICTA has developed text-mining technology to automatically detect cases of patients with IFD from the text in reports of medical imaging performed on them.
“We wondered if something could be done to make that radiology report more useful to the clinician, and to hospital administration observing that particular types of infections might be occurring in a certain ward, for example,” Hanlen explained.
“How could we get more information out of the same report without the radiologist having to enter more information? We built a traffic light demonstrator that showed particular wards or beds could have recurring infections.
We focused on improving outcomes for clinicians, administrators and patients without people having to add more information. We wanted to make the data work harder, not the people.”

TAKING TECHNOLOGY PERSONALLY
While e-Health may not always be an obvious element of innovations in healthcare, perhaps one of the most high-profile initiatives is the introduction of the Personally Controlled Electronic Health
Record (PCEHR). As part of the Australian government’s National Health Reform agenda, a shared electronic health record system was launched on 1 July, 2012. From that date, patients could choose to register for a shared e-Health record. The purpose of the PCEHR is to record key patient health information and, with consent, to share this information with other healthcare providers.
“The idea seems like a no-brainer,” says Dr Chris Moy, an Adelaide GP who was the Australian Medical Association (AMA) advisor on PCEHR in 2012. “The problem is that there was a perception that the record would be patient-controlled, and so funding was put in to make PCEHR acceptable for consumers. But the people who use the records are the doctors. As a doctor, you are providing data but if the patient can control that data and perhaps remove something, can you then trust the data? And what if data is missed – are you legally exposed as a health provider if you miss something on the record?”
Moy says a concern for the AMA has been the lack of financial support available to doctors to put the PCEHR system in train, e.g. to curate their notes and upload information to PCEHR, to train-up on how to use the PCEHR system effectively, and to sign up patients.

THE CHALLENGES OF PCEHR
Moy says the interface between the existing software used in most GP clinics and the new PCEHR system was initially “horrendous”. “It was hard to find a record, hard to upload information and it didn’t fit with our workflow, but in the
past year there has been progress,” he says.
“The product is being improved so it will have better functionality and useability and there will hopefully be increased legal protections for doctors using PCEHR, so doctors will be more likely to use it I think.”
The federal government is considering changes to the PCEHR scheme after a review highlighted some flaws and foibles in the existing scheme. Recommendations include operating the system as an opt-out scheme for patients, rather than relying on patients opting in, and renaming it My Health Record – MyHR. The review also recommends making it clear to healthcare providers when patients change or withhold information in their health record. Around $140 million has been committed to continue the rollout of the scheme.
Moy is quick to add that the AMA supports the aims of the PCEHR and the benefits it offers, particularly for patients. “Wherever you are, it makes your health record available – so if you travel interstate, get sick and end up in hospital, that hospital can see your medical history, what you are allergic to, and what medications you are on. It would mean people don’t get adverse events, there is non-duplication of medicine and testing, and health professionals can make a better clinical decision with the data in front of them.
“We have been critical of the way it has been done but we support the system because we see the ultimate benefits for patients. It’s just common sense that this system should be there.”
Similarly, the Royal Australian College of General Practitioners (RACGP) is supportive of the potential positives of e-Health initiatives, such as PCEHR, but agrees that some aspects warrant closer monitoring and refinement. “If you allow any healthcare provider to log in and upload information to files, how do you make that clinically meaningful, and how do you avoid death
by data?” asks Dr Nathan
Pinskier, RACGP chair of health information systems.
“We need to understand how to put the technology to best use – as with the smartphone. It has now been around for years and has been refined to be useful.”

GREATER INTERCONNECTIVITY…
Pinskier adds that while there has been a focus on establishing a national health repository to store patients’ clinical information, the ability for healthcare providers to interconnect should be a priority.
“There are a number of solutions that currently don’t talk to each other,” he says.
“It’s like with mobile phones. You may be with Optus or Vodafone or Telstra or Virgin and if you want to call someone who is with Optus, you have to have an Optus phone. If you want to call someone who is with Vodafone, you also have to have a phone with Vodafone. So you might need five different mobiles in your pocket to connect with the people you want to talk to.
“But I can only send to, and receive from, a specialist if they are in my community of interest and I don’t want to have to sign up to four or five different providers to be able to reach other specialists. In the banking world, we can withdraw money from any other bank’s ATM, because they are interconnected. We need to establish some similar rules to make this happen.”

…AND FACE-TO-FACE CONSULTATIONS
Pinskier also emphasises that while electronic technologies undoubtedly bring advances and benefits to the healthcare system and those using it, the RACGP believes the gold standard of a clinical consultation is a face-to-face consult.
“Telehealth offers great opportunity to provide services where face-to-face consultations aren’t possible or accessible, but the face-to-face model has worked well in this country for a long time and general practice forms the cornerstone of health delivery in Australia,” he says.
“The average Australian will see a GP six times a year and we want to ensure the robust model of healthcare around access to practitioners continues to thrive. Anything that erodes that patient/practitioner relationship causes
us concern.”
The Telehealth Financial Incentives Program that provided incentives to eligible health professionals to conduct telehealth consultations ceased on 30 June. However, the Telehealth Medicare Benefits Schedule items remained the same. As at end of March 2014, the Department of Human Services had processed more than 169,000 telehealth services provided to over 62,000 patients by more than 9,700 practitioners, says Medicare. Most of those services (109,997) were provided by specialists, 58,925 were provided by GPs, and midwives and nurse practitioners provided the remainder.
Anne Cheetham is national programme manager with Ajilon, a major business and IT consulting company working within the health sector. Cheetham is also chair of a special interest group for e-Health within the Australian Information Industry Association, the peak body for the ICT industry in Australia.
Ajilon has developed a number of tailored ICT solutions for the health sector, working with public and private sector organisations. The company has, for example, delivered an interface to ECLIPSE – the electronic interface or message exchange between hospitals – for the private health insurer, HBF. ECLIPSE provides paperless processing and the interface
allows HBF to receive hospital claims electronically – reducing processing times by at least 50 per cent. It has also led to more accurate processing and reduced processing costs.
Ajilon has health clients
in Western Australia, NSW, Canberra, Queensland and Adelaide, including Departments
of Health in those states.

BUSINESS AND TECHNICAL DISRUPTERS
Cheetham believes the energy for innovation in the health sector is coming from two disrupters – business disrupters and technical disrupters. She identifies business disrupters as legislative changes, financial events such as funding cuts in the most recent federal budget, and the rise in consumer expectations for quality of service and empowerment, such as readiness to question the advice from a GP and seek a second opinion.
Technical disrupters include the National Broadband Network (NBN), which will enable remote telehealth and mobile technology such as iPads for community nurses and SMS reminders of medical appointments.
“There is also big data, which is not new in a business sense but we’ll see the harnessing of massive computing power to crunch numbers more quickly,” says Cheetham. “And of course there is the cloud, which is the only sensible answer for storage and retrieval of the massive amounts of health data we are now generating in electronic form.”

SHARING, STORAGE, SECURITY
Cheetham believes the NBN will be influential and we are only seeing the tip of its potential right now. “NBN is the enabling mechanism for telehealth and there is scope for the NBN to enable innovation in the health space that most of us have not thought about yet,” she says.
“You can take a file the size of an X-ray, for example, and make that available on a mobile device to a specialist in a different city or country and you could have experts sharing test results as if they were face-to-face.”
Cheetham is also clear on the benefits for healthcare systems of the cloud.
“It makes no sense for individual hospitals or health districts to maintain large infrastructures in-house with all the associated costs. So cloud (use) is an inevitability,” she says.
“But what will slow it down is the dichotomy – is the confidential patient data any less safe and secure in the cloud than it is in our own data centre? Most people are still a bit cloudy on what the cloud actually is, so I think there is some resistance to putting that kind of data in the cloud in case it falls into the wrong hands. The misconception is that information is less safe in the cloud, when in most cases it is better protected there.”
Cheetham sees Australia potentially treading a similar e-Health path to the US.
“They have the incentive and the deeper pockets and they seem to be bringing more of the business world into how you administer healthcare. In the same way you might go to a supermarket to buy your veggies, or top-up your mobile – in the US they have a shopfront and you can buy whatever online services you need and get access to a qualified health practitioner. He or she may be on the other side of the country but I think we overstate the assumption that every time we get advice from a health practitioner we want it to be the same person. I think in a busy world, people want more of a one-stop shop,” she says.
“We need to stay nimble and not base long-term decisions on preconceptions that things will always be done in the way they’ve been done in the past.”

WHAT LIES AHEAD
Change inevitably takes time and brings challenges, and the e-Health revolution is no exception. Cost, proof of efficiency and safety, and education and awareness are all key planks in the push towards the greater use of technology in healthcare.
In outlining the benefits of e-Health, the National E-Health Strategy highlighted the harsh realities facing Australia’s health system. The ratio of healthcare spending as a proportion of GDP is expected to rise from 9 per cent currently to an estimated 16 to 20 per cent of GDP by 2045.
“Any ability to constrain growing healthcare costs will directly support the future sustainability of the Australian healthcare system,” the strategy says. “A nationally coordinated approach to e-Health will contribute to this outcome by improving the capacity of the Australian health system to do more with existing resources and by enabling these resources to be deployed against real need. This will result from improving system quality and safety (and therefore reducing avoidable demand for healthcare services), improving system accessibility and improving system processing and cost efficiency.”
Leif Hanlen at NICTA says there is a growing understanding across the health sector of adopting an approach where ICT research sees organisations provide capabilities that are then discussed with the end-users in the health system. This discussion helps identify what is really necessary and an effective business model can be developed along the way.
“Telehealth has been understood as a useful technology since the 1980s – the technology isn’t the problem,” says Hanlen. “Difficulties arise in putting a product into the health application. ICT in health is often treated as strange and different. It’s done over there, in a lab, and somewhere near the end of the process attempts are made to put into the health space.
“But if you want the same quality and scale of health service delivered to more people by fewer people, you need to invest in something other than hiring more staff. That is where ICT efficiencies come in.”
In the telehealth sector, the One in Four Lives paper outlined the need for a national strategy that is “targeted, purposeful and efficient”. The paper’s authors said such a strategy would drive development of new business models and/or four clinical interventions, rather than passively accepting whatever comes our way.
“Telehealth could be marshalled to play a major role in enabling changes to the service models and delivery required to respond to the growing demand for healthcare in Australia,”’ say the authors.
Hansen believes patients will also drive changes and uptake of technology. “Patients get the best care and the safest care and it enables them to care for themselves more. But health professionals need help to manage the information overload coming through patient data and literature,” he says.
“Stumbling blocks are the costs and showing the effectiveness of moving to a more information-based healthcare system. There are very few health projects now where people aren’t asking how a solution will provide a more sustainable healthcare system.
“But I think patients will drive a lot of this. They will want access to information, to do more in managing their healthcare and they will want to be guided through mobile technology. The first person into the cardiac rehabilitation program was a 71-year-old man who had never used a mobile phone before. After six months, when the trial was over, he didn’t want to give the phone back – he loved putting in the data and looking after his own health.”

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