Telstra Health building the bridge that will take telehealth mainstream
Telstra Health is moving into the second phase in the development of the National Telehealth Connection Service (NTCS), which will allow hospitals and external healthcare providers to hook into health-grade telehealth networks through a common platform that also handles scheduling, referrals and clinical document exchange as well as a virtual meeting room for video conferencing.
Telstra Health was contracted last year by the Northern Territory government to begin the first phase of the project, which involved proof-of-concept technical and clinical trials in two Aboriginal communities to build them a private, secure video connection service solely for telehealth.
Those two communities – Santa Teresa, about an hour out of Alice Springs, and the Anyinginyi Health Aboriginal Corporation in Tennant Creek – are now up and running with dedicated services that connect into NT Health’s existing telehealth network via NTCS to allow hospital-based specialists to provide remote medical services such as outpatient clinics.
The South Australian Department of Health has also come on board to provide remote video consultations from its hospital specialists to NT patients as a part of moves to make it a truly national service and reduce the need for clinicians to travel north and patients to head south.
The project is now moving into a new phase, in which non-government healthcare providers such as GPs, aged care facilities and Aboriginal Medical Services and consumers themselves can also access health-grade networks, no matter which proprietary equipment they currently use. Scheduling, referrals and store and forward functionality are due to be added shortly, followed by the capability to share a patient record and the integration of various billing systems and payment methods.
The aim is to build a platform that provides a virtual meeting room that providers and patients can dial into no matter what internet service or video conferencing equipment they use, that also handles scheduling, billing and data exchange, and contains a directory of telehealth providers for referral purposes. In effect, the idea behind the NTCS is to finally take telehealth mainstream.
According to Telstra Health’s chief health information officer David Doolan, the NTCS is primarily an initiative of the National Health CIO Forum, which allocated funding to NT Health to go out to tender for a proof of concept for a telehealth connection system. Telstra Health won that tender in late 2013.
Dr Doolan said the underlying issue for the NT, just like the other jurisdictions, is that while it has fast, health-grade telehealth networks operating in public hospitals and between sites, there are numerous community-based healthcare providers who don’t have the technical capability to access those networks.
There are also complex challenges in how telehealth services are paid for and how to do referrals and scheduling of appointments.
“In the NT’s case, there are quite a lot of non-government Aboriginal Medical Services that are basically small businesses with variable internet connections,” Dr Doolan said.
“The first priority in the Northern Territory was to reliably connect to Aboriginal Medical Services that weren’t on the government network. We spent some time trying to find the right partners because at the end of the day it was a technical concept but we didn’t want to do it where there were no patients who would benefit. So the two sites picked were Anyinginyi near Tennant Creek and Santa Teresa, which is just out of Alice Springs.”
Dr Doolan said Telstra Health and NT Health worked closely with the the Aboriginal Medical Services Alliance Northern Territory (AMSANT), which has extensive experience in telehealth and eHealth and which provided technical, facilitation and other services on the project.
“In the first instance, the sites wanted a dedicated connection as well as a reliable way to do telehealth,” Dr Doolan said. “The NT people wanted to be able to use whatever video endpoints and whatever bridges they are using on their side, and to dial in as if they were dialling into their own network. They also wanted the people on the other side to use whatever equipment was in place there.
“The other issue was that these two sites wanted a dedicated connection and wanted bandwidth dedicated to video. They wanted us to provide quality of service (QoS) across that connection so that when they are running video, we give them guaranteed bandwidth on that pipe to connect to the service so if someone started using the internet to download a PACS image or whatever, it didn’t interfere with the video.”
Dr Doolan said the two sites had their existing hardware upgraded and they now have a private, secure, cloud-based video connection service. “We stood that up in health-grade infrastructure with all of the usual fail-overs and security, and then we directly connected to the Northern Territory health network, which meant that any endpoint or any site provided by NT Health could use the service,” he said.
“Then we directly connected to Anyinginyi and Santa Teresa, because they were running on their own local area network. Once that was established in the second half of last year, we started a clinical proof of concept going into May this year and they are using it to provide clinical services at those sites.”
CIO direction
Telstra Health is building the NTCS under the direction of the National Health CIO Forum, which involves all of the state and territory health department CIOs, and the National Telehealth Reference Group, which has recently been re-established to provide direction on what technology should be pursued, what functionality should be built and what sectors are the priority.
For the NT government that is the Aboriginal Medical Services (AMS) and Aboriginal community-controlled health services. As part of Telstra’s reconciliation action plan, Telstra Health is working with NT Health to connect 15 more AMSs to the network next year.
“We are also in conversation with other providers at a government and individual health service level across Australia,” Dr Doolan said.
While he can’t discuss the details of those conversations, Telstra Health is more than aware that it must build scale and sustainability in order to achieve the goal of taking telehealth mainstream.
“A lot of people have relied on pilot money for this but it has to get to the point where it is so easy to do and so mainstream that people just do it,” he said. “That’s what we are pushing towards, both in making the technology approachable and flexible and you don’t need training to use it, and making things work.
“We are steering right away from proprietary technology. We are using open standards-based technology, so we don’t care what one sort of technology is on one end and the other has on the other end. As long as it is adhering to a certain standard, then we can scale right down to a consumer.”
While the initial impetus in the Northern Territory was organisation to organisation connections, Dr Doolan said the company is working to open up access to the service via the internet, so small providers and consumers themselves can use it.
Telstra Health won’t be able to guarantee the same QoS that a health-grade, dedicated channel provides as it can’t control the final end of the pipe, Dr Doolan said, but it can provide the same experience in terms of standards-based, single points of access, as well as providing scheduling capability on the platform itself so users can schedule events and notify each other using email or SMS notifications.
Email and SMS are not secure enough to swap clinical information, so the next phase of functionality that the telehealth reference group has asked Telstra Health to build is a platform on which clinical data and medical images can be exchanged – both physically by moving data and virtually by displaying the data on the screen – and the all-important referrals.
“We’ve got a strong belief, and this has been validated by others, that clinicians don’t want telehealth referrals to be different to any other referrals – they want to make it mainstream,” Dr Doolan said. “They say, give me the option of referring to telehealth upfront and then give me and the patient the option of whether we want to do it, but don’t make it special or separate, otherwise we won’t use it.”
Virtual meeting rooms
Telstra is also working to ensure that its own existing and new telehealth services, including the ReadyCare service for GP-to-patient telehealth, the Anywhere Healthcare service it purchased from Medibank Health Solutions for GP-specialist-patient consults and the MyCareManager telehealth-enabled device it has built for aged and community care are all compatible on the same platform.
“We don’t want a situation where if we have provided a device for someone in their own home to let them monitor their vital signs and do video when required, we don’t want that consumer to have a different experience when they are accessing a specialist,” he said.
“We are putting all of this technology and functionality on the same platform on our side in order that people can have a common experience.”
That will mean using a standard approach of virtual meeting rooms so participants can meet in the middle and do away with the requirement to know how to dial into the address at the other end.
“That also allows us to set up virtual waiting rooms,” Dr Doolan said. “At the end of the day when people see providers face to face there are a whole lot of things that go on – scheduling, billing, exchange of data, whatever. All of that has to happen when you do telehealth and just because you don’t have a physical waiting room doesn’t mean that you can’t have a waiting room.
“You have to have a virtual waiting room so the providers know which patients are ready for a call and which aren’t. People have got around this problem in the past by having extra people and extra logistical resources running around organising telehealth and chasing phone calls, and some of that still will persist, but we need to minimise the number of resources that are required.”
Telstra Health also hopes to help overcome one of the biggest challenges: how the actual video consultations are paid for and who by. This is one of the most complex areas for telehealth considering the multiple funding streams available, from MBS-funded specialist consultations to privately billed GP services, different arrangements for residential aged care providers and those paid for by hospitals, as well as federal and state-funded patient transport subsidy schemes.
“We are trying to get technology to a certain scale that the price point for it, people can consume it as a service and that make sense because it is saving them money or time or giving them convenience,” he said.
“In terms of providing billing, with our Anywhere Healthcare service where we facilitate consumer or GP access to specialist services, where those specialists are able to bill Medicare, we provide that billing platform. Where that service is being provided by some other mechanism, we provide a single reporting reconciliation, so people know what service has been provided and what they have paid for.”
Telstra Health intends to make the NTCS so easy to use that video conferencing will be as simple as clicking a few links, but it is also helping to build a national directory of telehealth providers for referral purposes.
It will use the National Health Services Directory (NHSD) – which Telstra Health’s subsidiary HealthConnex has designed and maintains on behalf of Healthdirect – as a directory to facilitate telehealth referrals, Dr Doolan said.
“Where the provider directory is more relevant is when you are referring a patient to someone else and it’s less important when you actually go to do the video conferencing. What we try to do is take that problem away by making people meet in the middle and providing scheduling, so when it is time, you use whatever piece of equipment you’ve got to join the virtual meeting room.
“A directory is less important at that stage but a directory is vital, however, when you are making the referral and making the choice. We are committed to using the NHSD, which needs ongoing development to facilitate telehealth as well as any other referral or access point for patients.”
Referrals
For the exchange of clinical documents and images, how the platform works will depended on the providers, he said. In the case of a scheduled event such as an outpatients visit or a multi-disciplinary team, it often comes about from a referral and you know that event is going to occur.
“In advance, as part of the referral, you make sure the right information gets to the right people. It is scheduled, you know it is going to happen and you can get organised in advance. That is different to an emergency or ad hoc service, in which case you need to be able to exchange data with people that five minutes ago you didn’t know you were going to call. That’s a bit more problematic.
“Sometimes it’s not sharing of content but sharing of screens – sending virtual images but the data is not really leaving one place and going to another. There is also a requirement that after that fact there is record of what happened, and obviously you need to share what a clinician on one end advised a clinician on the other end to do.
“That’s less of a referral or store-forward issue than it is an exchange of data in real time. In some instances it is easier if you don’t have to move data and you just need to share a view of the data, but if you really want to move the data around that is where things like a digital archive come in, which is technology that we have.”
The NTCS looks likely to be a long-term project that Telstra Health is just now having discussions with the other jurisdictions beyond NT Health and SA Health. Dr Doolan said the immediate value offering with the service was the ability to be a bridge between the state-run telehealth networks used by hospitals and with external providers.
“It is obviously very difficult for them to deal with the hundreds or thousands of GPs, aged care facilities and Aboriginal Medical Services so that is the first value offering,” he said.
“Ultimately we’d like to see a situation where people look at this sort of service and say they can use it for their own or some of their own platform, or if they have a certain cap on their volume to access our services.
“One example of that is we are working with a number of smaller providers at the moment who generally are only doing one telehealth event at a time but now and then they need to be able to scale up. They might want to do a multi-disciplinary team meeting and involve 10 endpoints instead of two.
“By using us as a service, we can say that on a regular basis you can have access to one virtual room, because that’s all you need, but you tell us when you need to scale up, which might be once a week or once a month, and we’ll give you the ability to scale up and down.
“Having said that, technology is not the important thing. It is the clinical workflows, the clinical networks and that’s why we work closely with the providers and the consumers to understand what it is they want, which isn’t necessarily what the technology does.”