To Skype or not to Skype

This article first appeared in the July 2012 edition of Pulse+IT Magazine.
Probably the most contentious issue in the move towards greater telehealth use in Australia is whether or not consumer-grade video conferencing applications such as Skype are adequate for medical-grade consultations. Software vendors will tell you no, users will tell you yes and the experts fall somewhere in between.

One of the reasons behind the large amount of money the federal government is currently spending on telehealth – and its recent changes to the incentive program – is to encourage faster uptake of video conferencing services. In addition to the one-off incentives to invest in equipment, there is ongoing support through the MBS to continue to use video conferencing after the initial investment is made.

So, why not use common and cheap options such as Skype, the world’s most popular means of video conferencing, or Apple’s FaceTime, which is available on its devices such as iPhones and iPads for mobile video conferencing as well as between Mac users?

The reasons against using Skype for clinical video conferencing are many and varied, but the reasons for using it are simple: it is cheap, easy to use and gets the job done.

First up, the no camp. In an excellent article in the March 2012 issue of the RACGP’s Good Practice magazine, Trish Williams of the School of Computer and Security Science at Edith Cowan University laid out in plain English why it was not necessarily a good thing to use Skype in clinical practice.

According to Dr Williams, Skype was not designed with healthcare in mind and it does not have the level of confidentiality and quality of service required for patient video consultations. She writes that the benefits of Skype are obvious: it is low cost, it is easy to use, it has some security factors built in such as encrypted video and voice communication between Skype users, and if you are still worried about security, you can add encryption software if you so choose.

However, there are a number of reasons why Skype may not be a good option, she says. There is no guarantee of the quality of transmission, the video function in Skype uses up bandwidth, there is no interoperability with other video programs, file transfers are vulnerable to infection and there are potential issues with spyware.

And for clinical consults, where privacy is paramount, Skype has a major failing. Although it does use digital certificates for log-ins, there is no guarantee that the person you are talking to is actually that person. “Skype requires registration and names that are accessible by others using Skype,” Dr Williams writes. “This means impersonation is a risk.”

She also says that there is no guarantee of the routing path of messages through networks, which may contravene Australian privacy legislation. In short, she does not recommend Skype for use in general practice.

Gary Holzer, business development manager with South Australian-based clinical software and telehealth developer Healthbank Consult, calls Skype “his worst nightmare”. That’s not just due to the ubiquity of Skype – there are 250 million users worldwide and the Microsoft-owned company is aiming for one billion users in total – but what he says is its unsuitability for clinical use.

Healthbank Consult is an integrated software product that can be used with off-the-shelf video conferencing equipment, but like many other products on the market, it sells itself on the ability to be integrated with clinical software, in this case an electronic health record the company also markets. By using a packaged product like Healthbank Consult, clinicians can share referrals, reports and images during the video consult.

However, Mr Holzer says the real power in a proprietary product for clinical use is the database of users that underpins it. Healthbank Consult has a network of specialists using the system who are available for referrals, which the company is now taking Australia-wide. “GPs don’t want to talk to just anyone — they want to talk to their specialists as their patients already have an ongoing relationships with these doctors,” Mr Holzer says. “This is one message that has come across loudly and clearly from the GPs. You have to build the network to sell the service.”

His company has absolutely no plans to allow the product to be compatible with Skype users. “It doesn’t interface with Skype and nor do we really want it to. Nothing integrates with Skype. Skype is my worst-case scenario with a GP clinic … besides all the security and other issues, why would the government give you $6000 for free?”

Mr Holzer believes GPs and specialists should not use office or home-grade solutions as they are not medically safe. He points to the RACGP guidelines, which recommend instead medical-grade solutions that store data here in Australia.

“[The RACGP guidelines] talk about how it needs to be clinically appropriate,” he says. “Under the national privacy principles, if you are using a telehealth service such as a webinar service like WebEx, which is a cloud-based service, that is based in Singapore. Using these office-based solutions, where is the data going to be held? It could be overseas.”

Gundagai-based GP Paul Mara dismisses many of these concerns. He remains skeptical of the practical value of many video consults in the first place, but his practice has done several using Skype recently and he can definitely see a role, not to replace face to face consultations but to better support them.

It is the number of specialists who are available to do video consults that is the current deal-breaker for many GPs, and Dr Mara notes with amusement the increase in the number of specialists and GPs joining up to take advantage of the incentives before they dropped significantly on July 1.

“We have investigated a range of solutions and are currently using Skype,” he says. “At this stage it is the simplest and to be quite honest the most effective solution that we’ve used. We had a look at a few other teleconferencing solutions and they were either too expensive or promise the earth but are not much better than Skype for the type of consultation we’re undertaking at present.”

He dismisses the arguments of many telehealth solution vendors that Skye is not high enough quality, or secure enough. “A lot of those people have a vested interest in selling a proprietary product. I’ve just got a vested interest in doing the thing that is the most efficient and cost-effective for the patient at the present time, given the technology that we’ve got.”

One of those limitations is of course broadband speed, which is even more problematic in regional Australia. “You can have the worst or the best pictures in the world,” he says. “We did a Skype the other day in the surgery and it was ADSL+2 at both ends and the actual video was quite good. But if you are trying to diagnose say a skin lesion, you have to do it in different ways. We would normally take a digital photo and send that down on an email and then have a discussion about it.

“You have to work within the limits of the technology at both ends. There is no point in us getting a special purpose set-up if we don’t have high-speed broadband and if at the other end they have an incompatible solution.”

Security concerns can also be over-blown, he says. “Where do you begin and end with the internet? We’ve had quite major breaches of privacy and confidentiality from Medicare, where patients have been sent wrong cheques with other people’s names on it.

“The other issue is faxes. If you are faxing a referral off, you don’t always get verification that it’s going to the right place. There are lots of holes in all of these systems and I would not see that Skype is any better or worse than any of them.

“The notion that you could log accidentally onto any car detailer or housewife or school kid and start having a video medical consultation is a bit rich. It would be nice to have total security and confidentiality and encryption happening, but as soon as you start putting encryption algorithms, with the speed of the internet at the moment the whole thing would become untenable."

Dr Mara believes that ultimately, the technology that is used has to be reflected in the scope of the consultation. "At this stage you wouldn’t propose a consultation that required significant hands-on physical examination by the specialist or real-time diagnosis of a skin lesion, no matter what the system.”

Another doctor who recommends the use of Skype is Melbourne GP Jonathan Brown, who recently designed a free service to link GPs and specialists interested in doing teleconsults through Skype.

Dr Brown's Consult Online site is completely free, includes easy steps to show practitioners how to download Skype and then register for ConsultOnline, and includes a list of the Medicare item numbers they need to claim a consult under the MBS.

He acknowledges that there is debate over the use of Skype for teleconferencing due to its lack of privacy settings and resolution, but does not believe that practitioners need to purchase proprietary software for teleconferencing.

“You don't need it,” he said. “Consult Online.com.au works and is free. We performed a teleconsult today and the system works well. I think it's great that a rural doctor can ring a specialist quickly and easily and perhaps avoid the need for patients to travel long distances to see specialists.”

One who sits in the middle ground is David Allen, a Sydney occupational physician and member of the Australasian Telehealth Society, who has been using telehealth since 2007. His not-for-profit organisation Telehealth Solutions Australia uses Microsoft’s Lync solution rather than Skype, but he is aware of many doctors who choose the latter.

“What a lot of them are doing now is using Skype,” he says. “Skype has had a lot of criticism flung at it for various reasons but the issue at the moment, like anything in eHealth, is managing change, and changing the way people practice. Just as it is for the PCEHR, getting doctors on board with that is going to be a challenge.”

Having been involved in telehealth for a number of years, Dr Allen has closely followed the argy bargy over Skype, security and the practicalities of video conferencing in healthcare. Like Dr Mara, he says there are both pros and cons to using Skype and other consumer services.

“Everyone worries about security and quality and that sort of thing but that stuff is pretty easy to do,” he says. “Most of the solutions will give you adequate security. What Skype doesn’t give you is the resolution that you need for diagnostic stuff. You can have a chat but anything other than that…”

He also points out that consumer-grade video chat software doesn’t look terribly professional. “And there is no way of validating who anyone is at the other end of the line. Anyone can register on Skype as Dr Smith or whatever. There is the potential for people to impersonate. And it tends to suck up bandwidth.

“But if it has the potential to get people involved … this is about delivering care, not about doctors or technology but about patients accessing care. People need to think about that – not think about technology and get obsessed with it, but think about how you deliver care to patients.

”People keep throwing technology at doctors and they throw their hands in the air and go it’s all too hard. It has got to be made as easy and accessible as possible.”

Posted in Australian eHealth

Comments   

# Ian 2012-07-21 12:18
If you are finding that the Microsoft Lync URL in the article above is not working then try this instead: http://lync.microsoft.com/en-us/Pages/unified-communications.aspx
# SJ 2012-07-21 13:47
Thanks Ian, that link has now been corrected.
# Vicki Sheedy 2012-07-23 08:57
ACRRM has developed a guide for clinicians to mitigate risks when using Skype for telehealth. Some rural GPs are limited to using Skype for some of their telehealth consultations because it is the only product that the current referral specialist is prepared to use. Risks must take into account the risk of not providing the consultations with the patients current specialist vs the risks of using Skype. Continuity of care is important.

The Guide is available to all registered users on www.acrrm.ehealth.org.au
( its free to register)
# Anton Cush 2012-07-24 09:17
I would like to hear some perspectives from the e-Health community on the recent changes to Skype's integrity. An article published last week on Slate, outlines that the service may now be subject to eavesdropping. Does this affect telehealth applications of Skype? http://www.slate.com/blogs/future_tense/2012/07/20/skype_won_t_comment_on_whether_it_can_now_eavesdrop_on_conversations_.html
# Janelle Jakowenko 2012-07-26 04:28
The RACGP have a new resource: "Advice on using Skype" can be found at www.racgp.org.au/telehealth/gettingstarted

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