Cystic fibrosis project to trial WebRTC and shared EHR
The Victorian government is funding a new project to improve access to care for people with cystic fibrosis living in regional areas, using a combination of technologies including WebRTC-enabled telehealth, remote monitoring devices and a shared electronic health record.
The Regional Cystic Fibrosis e-Health & Telemonitoring Program is being funded by the Victorian government's Broadband Enabled Innovation Program and the Victorian Department of Health, and will be undertaken by Monash University.
The project is designed to remotely monitor patients at home and deliver more services online, with patients able to view care plans and radiology images from home and take part in video consultations, which are expected to include the use of the browser-based WebRTC technology, an open-source approach with implementation being led by Google and Mozilla.
Patients will also be able to access a portal to participate in their own treatment programs, with the measurements and data collected by the remote monitoring devices integrated into a shared EHR.
The project is being led by John Wilson (pictured top left), the head of the Cystic Fibrosis Service at Alfred Health and a professor in Monash University's Faculty of Medicine, Nursing and Health Sciences.
“Telemedicine is an opportunity to provided better access, improved monitoring and prolonged treatment courses for many patients who would otherwise be dependent on hospital care,” Professor Wilson said.
“The cutting-edge of telemedicine lies in the ability to monitor many conditions in the home environment using high-speed broadband. The Monash team have accomplished this by providing healthcare solutions suitable for implementation within the Australian community.”
The project also includes Monash Medical Centre, the Royal Children’s Hospital, Alfred Health and Cystic Fibrosis Victoria.
The shared EHR, which will be enhanced to include a patient portal and to receive and store home monitoring data, is being provided by Smart Health Solutions, which has developed its technology to improve care for several chronic disease groups, including people living with cystic fibrosis.
The WebRTC technology will be enabled through video consultation specialist Attend Anywhere's management and integration capability. Risk management solutions specialist Riskman International will provide its enterprise risk management system, although the provider of remote monitoring technology has yet to be decided.
Attend Anywhere managing director Chris Ryan said the development of WebRTC will be a major game-changer, not just for telehealth but for all real time communications. In addition to The Alfred, Mr Ryan said major clients such as Healthdirect Australia have already recognised the potential and are gearing up to take advantage of the technology across a number of services.
WebRTC is generating great interest in the telehealth and telemedicine sectors. As opposed to proprietary video conferencing solutions or popular free services like Skype which require user accounts, WebRTC is a draft web standard for real time communications built into web browsers.
The technology allows video or audio communications along with real-time data transfer between web browsers such as Chrome and Firefox. Microsoft is also taking part in the development of the technology for Internet Explorer, and Mr Ryan said it is already working on Android devices in beta mode.
“WebRTC is still in its very early stages, with some important parts of the picture still missing,” he said. “Although mainstream support in all browsers, support for mobiles and a more complete set of capabilities is expected to arrive in the next 12 months, we are not expecting this to be all smooth sailing until the standards and their implementations have stabilised.”
Draft standards for the API have been written by the World Wide Web Consortium (W3C) and draft standards for the media component by the Internet Engineering Task Force (IETF). While there is still some “wrangling” going on, as Mr Ryan describes it, the standard is expected to be ratified within months.
“It has already been implemented in Firefox and Chrome and with a very streamlined plug-in for Internet Explorer,” Mr Ryan said. “Because it’s been designed from the ground up to allow standards-based real time communications over the internet, it works very well, and provides very high quality video and audio.”
Mr Ryan said the development of WebRTC had been remarkably fast, as browser standards only require a few large companies to agree on them, as opposed to telecommunications standards which require hundreds of companies to agree and then build them into product development life cycles.
“We are seeing weekly improvements that are literally promulgated worldwide overnight, in automatic browser updates,” he said. “If you think about the impact of web standards on the way that we communicate, it's absolutely game changing.
“This is a web standard for incredible quality, secure video conferencing that is highly scalable, resilient and interoperable between devices. The technology works peer to peer between browsers so the only cost for the majority of calls is the user’s internet. Central costs are tiny, even to support massive volume.
“With no software downloads, the user experience is incredibly streamlined and there's no echo, even using standard computer speakers. It's safe to say we are pretty excited by it. You will also be able to make or accept calls through WebRTC to traditional SIP-based video and telephony systems, which is another part of the puzzle.”
As part of the cystic fibrosis project, Attend Anywhere is developing a interface to the EHR and patient portal that will allow video or audio calls using WebRTC to go directly to the project's landing page.
“[Patients] either enter a scheduled [video consultation] appointment or you go in and you literally click on the service you want to access – it's like walking through a surgery front door and taking a number,” Mr Ryan said. “The service knows people are waiting, can choose which ones to attend to first and callers can be transferred to other service queues if necessary.”
One of the new capabilities that will be enabled by WebRTC is a secure data connection between the browsers. The ability to drag and drop images or files into the web browser during a video call is expected to much improve real-time collaboration.
In a video consultation, for instance, a doctor can securely deliver an ePrescription barcode to a patient at the other end in real time or one doctor can drag and drop an x-ray or a note allowing another doctor to receive the file securely and immediately. (For a demonstration of how the drag and drop function and browser-to-browser video conferencing works, see these videos here and here.)
Mr Ryan said Google's voice to text technology could also be used, meaning clinicians can conduct video consultations with hearing-impaired patients almost immediately.
“Everything that I'm saying could come out as a text, and the quality of the transcribing is very accurate,” he said. “There is so much innovation made possible by the fact that you are in a web browser for your video call.”
Attend Anywhere provides telehealth advice and program management services to the Cystic Fibrosis Service at Alfred Health, which has also worked with Smart Health Solutions for many years. Smart Health's director, Jon Hughes, said his company's technology had been supporting the cystic fibrosis patient program in Australian centres for a decade.
“We have a shared electronic health record that has been around for about 13 years, and the market is finally catching up with us!” Mr Hughes said. “Our solution predates the PCEHR and is currently being enhanced to interoperate with it, including the use of NASH PKI, Australian Health Identifiers, and an interface to the PCEHR itself.
“On our platform we have implemented support for a number of chronic disease management programs, the first of which was cystic fibrosis but which now also includes kidney disease, infectious diseases, cancer, homeless health and diabetes.”
Smart Health's technology can provide electronic reporting data to the National Cystic Fibrosis Data Registry, which Mr Hughes said was a real time-saver for cystic fibrosis practices. The National Cystic Fibrosis Data Registry was first established in 1996, and holds a complete and thorough record of all people in Australia who have CF. It also enables centre-by-centre comparison of clinical performance.
Mr Hughes said the new project will also provide an opportunity to investigate further integration of telehealth with eHealth records.
“This project will integrate home monitoring systems into our EHR,” he said. “Cystic fibrosis patients can record a lot of data in home monitoring systems – lung function results, blood glucose, oxygen saturation, weight and blood pressure – as well as health questionnaires.
“This project will integrate that data with the clinical data that we currently import from healthcare information systems such as hospital diagnostic services like pathology, lung function and diagnostic imaging, hospital patient administration systems and from private diagnostic services. We want to ensure that all of this information can be made available to all of the members of the patient’s healthcare team, regardless of where they are physically located.”
Professor Wilson said part of the funding would help pay for the development of the software and the interfaces but that it was also a full clinical trial.
“It will look at what factors can help us better implement home monitoring,” he said. “It is a way to enhance the EHR and will test a number of different devices.”
He said a statistically significant number of patients living in regional areas would be recruited and there were three main aims for the project. The first is to improve the management of new medical problems, such as a rise in temperature that might signify a change in a patient's condition.
“The second will look at the procedure and whether patients can be safely managed at home and we can monitor their progress, and the third is that these patients have a long-standing illness and we can more regularly review them.”
Faster interventions will be possible as clinicians will be online and will be able to quickly refer patients to local emergency departments, he said. “It will also try to improve access to healthcare for patients in rural areas and eliminate the gradient in healthcare, where rural patients have poorer access to services in comparison to people in capital cities.
“The outcomes will test whether we can save time, money and convenience for patients. It will also test whether the community has been provided with better care. The indicators for success will be improvements in clinical performance, cost benefit, and better access for patients.”
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