Where to for telehealth?
Describing what’s needed for telehealth as the “eHarmony for eHealth” is certainly one way of getting people talking, and that's exactly what the RACGP's eHealth manager Judy Evans did after the recent Australian Telehealth Conference.
Chris Ryan, principal telehealth consultant at Attend Anywhere and part of the steering commitee of the conference, said the description summed up one of the challenges facing wider use of telehealth as simply a normal part of healthcare delivery in Australia.
“One challenge for telehealth, as with eHarmony, is that connecting the right people is the hard part,” Mr Ryan said. “There's no point in just having a list of all the people wanting romantic partners and then all of the romantic partners available and expect that that is going to work. The role of eHarmony is to be more sophisticated and supportive in the matching process. That's really what we need to do for telehealth.”
Mr Ryan said access to service providers – and specialist services in particular – has always been the biggest barrier in telehealth.
“Like the health system itself, this is a complex issue that is different for different specialities, specialists and geographies,” he said. “The National Health Services Directory and services like the ACRRM telehealth directory will need to offer service providers the flexibility and confidence to control who they provide telehealth access to and for what.”
Mr Ryan said that based on his experience and the feedback from conference attendees, this year's event reflected some exciting aspects of where things have evolved to and where they are headed. He quoted NEHTA's head of strategy, John Zelcer, who said "the genie is out of the bottle" and feels the sector has moved beyond debating the virtues of telehealth to focusing on how to do it better.
Mr Ryan said people were realising that the technology underlying telehealth provision can be reasonably straightforward, but the management layer of the service is where the focus needs to be. He said the conference also showed that telehealth and eHealth are an integral part of the same conversation and that all forms of eHealth, especially access to a shared record, were a fundamental enabler of telehealth.
"The conference highlighted the varying practical needs and perspectives arising from experiences in different settings," he said. "The small business environment in primary and specialist care, for example, is quite different to the public hospital setting or the consumer setting. We need to continue leveraging and improving infrastructure investments in the public hospitals at the same time as taking to care to not build historical restrictions into future designs or other parts of the system.”
And while some might not want to hear it, he believes we have gone beyond the need to use incentives such as the MBS telehealth payment to get clinicians and patients participating in telehealth.
“The ongoing debate around a range of telehealth-related issues is great and I would like to offer a perspective on three aspects,” he said.
“The first is that the discourse around strategy, be it at a local, state or national level, quickly gets confused when people try and talk about telehealth as a single topic, or somehow separate to mainstream healthcare debates. This topic is as broad as the health system itself and we need to separate the vertical issues that apply to a particular discipline or project such as resourcing, clinical and business benefits or implications from the horizontal ones.
“The practical, operational, logistical and infrastructure issues for the most part apply horizontally across the system. These issues are often underestimated, misinformed or over-complicated. For the most part they are not about the video technologies.
“While the technologies are becoming radically easier, commoditised and demystified thanks to a range of drivers and enablers, we still need to do more at the management, facilitation, integration and communication layer. This is the part that sits between the clinical services and all the various technologies and ideally should exist independently from both of these.”
Mr Ryan believes that little further investment in IT or communications infrastructure should be required on a project basis. “The focus of project funding should be on the vertical service factors that arise. Investments in practical capacity should apply across all the vertical service components."
And while the first round of MBS item rebates was “world leading, system enabling and visionary”, the extra incentives might not necessarily be needed in future.
“That might be a little bit contentious and something no one really wants to hear, that they don't need money," he said. "There are people that will express the view that even the increased restrictions in the last budget threatened their business models.
“My point is that over the last 15 years, the practical issues aside, a lot of the challenge has simply been about being allowed to do it. For many clinicians a main barrier to adoption is simply not being allowed to consult via video through not being able to claim even the base MBS item. It’s not about incentives, especially now as the entry costs are so low.
"People shouldn’t read too much into the slow uptake of the early telepsychiatry items because at the time the practical barriers were just too high for most clinicians to contemplate. Had Skype existed back then it would have been a different story.
“The challenge with telehealth is that the actual and perceived costs are commonly incurred in a different part of the system (the provider end) to where the benefits are accrued. We need to allocate the costs to where the majority of the value lies and there is no reason why existing business models don’t apply.”
He said there are the same three cost components in telehealth as in physical appointments. These are the clinician; the service management, including practice staff and systems; and the travel.
“In a physical appointment, the patient or someone pays for the travel component and incurs the inconvenience and the lost productivity. The clinical service and the management components are bundled together in a service fee, which MBS partly covers and the patient pays any gap.
“In a telehealth scenario all three components are bundled together. The willingness of the person that saves the travel costs to pay a slightly higher gap would be a litmus test of the overall value.”
He also points to the “strange dichotomy” whereby some clinicians are being pushed to increase telehealth use through the carrot of MBS payments and equipment incentives, while in other areas restrictions are imposed for fear of too much use.
He believes that if arbitrary incentives are removed, the ability to claim just the base amount is broadened and the necessary checks and balances are put in place, “we would unleash the value of telehealth with far greater precision”.
“People would only do it where it made sense and there are plenty of natural drivers in the system to encourage take up in the right areas, including consumer expectations,” he said.
“Examples we heard at the conference, where imposing arbitrary restrictions didn’t make sense, include if a patient turns up physically at the Children’s Hospital in Melbourne they are seen by lower level clinicians but, via video, they have to be seen by one of the most expensive resources in the building – and we add a bonus payment on top!
“There were also examples where if a GP or an allied health professional were simply allowed to see someone via video, the value would be immense.”
Another aspect he thinks important to discuss is just how fragmented the telehealth sector is in Australia considering our population. “There are 15-20 organisations with missions to support telehealth within their various constituents and stakeholder groups that make up the health system,” he said. “We need a coordinated, open, and informed conversation around the horizontal, practical components that everyone shares and contributes to.
“Philosophically this cannot be under the auspices of a single ‘telehealth enabling’ organisation which brings individual perspectives, experience and priorities. It needs to be unbranded, for the benefit of everyone, but not owned by anyone and contributed to by people who know what they are talking about or at least have a mandate to learn before they lead.”
He said he hopes that the lead up to the 2013 conference is used as a catalyst for this conversation and that by then there will be a much larger, more diverse range of health professionals interested in becoming telehealth literate or looking for new ideas.
“The next generation will not know what telehealth is, it will just be ‘health’ and like email, people will take for granted they can access live services and information from wherever makes sense," he said. "The value and the need is immense in equal measure and it’s our job to make it happen.”
Posted in Australian eHealth