Kangaroos through the windscreen: the case for rural telehealth
Rural general practices looking to get in on the telehealth boom should remember to keep the technology simple, develop relationships with specialists and use telehealth to not only improve patient care but for clinical training as well, telehealth advocate Ewen McPhee believes.
Dr McPhee, who runs the Emerald Medical Centre in central Queensland, says his practice regularly does between 10 and 15 video consultations on any one day but has not had to invest in high-tech equipment. Telehealth is a sustainable business for the practice as there is funding through the federal government's telehealth incentives program, but the prime reason the practice offers telehealth is for better access to care for its patients.
Dr McPhee told an Australian College of Rural and Remote Medicine (ACRRM) webinar yesterday that the need for patients to travel long distances to see specialists is why telemedicine can be such an effective solution, for some but not all health-related problems.
Telehealth also offers teaching practices like his the opportunity to provide GP registrars with more advanced clinical training and the opportunity to sit in on specialist consultations. Practice nurses, nurse practitioners and allied health professionals also stand to benefit, he said.
Dr McPhee presented the webinar with his wife Wendy, who is also the practice manager. Emerald Medical Group has eight GPs on staff along with up to five GP registrars at a time, including rural generalists attached to Emerald Hospital who are based at the clinic during their rotations. Dr McPhee has visiting rights at the hospital for his obstetric patients.
The practice has been doing telemedicine in some form or another for a decade, but in the last 18 months has geared up its offering and now actively promotes it, to the point of putting a line on every specialist referral saying the practice is telehealth-enabled and would be happy to facilitate a telehealth consultation. While the practice is kept busy with GP telehealth consults, it is nurse-led consultations that are really taking off.
Dr McPhee said he advocates for telehealth because it is easy to use and can improve retention rates for rural clinicians, but also because it can reduce costs, both to the patient and the healthcare system.
“We've no doubt that distance creates barriers to care and this leads to poorer outcomes and increased costs,” he said. “The fact is a lot of those increased costs with the problems of accessing care for rural people are hidden and they are not measured. A lot of cost is borne by rural and remote people in accessing care that our city cousins simply don't have to do.”
He said while there had been a lot of debate about security issues, particularly the lack of security offered by Skype –which most specialists prefer to use – these issues are dwarfed by the benefits telehealth offers.
“It only takes one kangaroo through a windscreen to really justify telemedicine, and to be honest on some of our roads, it is more likely that you'll get a kangaroo through your windscreen than have a terrorist from Al-Qaeda listening in on your consult about your haemorrhoids.”
He is also an advocate for the benefits telehealth brings to rural practitioners themselves and in promoting rural practice.
“We have a number of general practice registrars and medical students attached to the practice, and we are actively engaged in supporting them with doing telemedicine,” he said. “There are a number of reasons for that. You can enhance rural retention through being the eyes and the ears and the hands of remote specialists. You can support and enhance clinical skills, and you can be – by beaming in your specialist or the clinician – a source of mentorship, back-up and pastoral care for very isolated clinicians.
“And for us, it has created some really close relationships between specialists and GPs, that we are enhancing the understanding of our specialist clinicians and basically giving them an understanding of the rural and remote context under which we live and work.”
The wider use of telehealth is now opening up in Queensland through measures such as the uncapping of the amount of telehealth that can be provided through rural hospitals by Queensland Health, as well as the establishment of new programs like the telemedicine emergency support unit (TEMSU) which seeks to provide a link between very isolated clinicians such as nurse practitioners in remote clinics with a regional doctor or emergency medicine physician.
“What we are seeing in central Queensland now is the ability for a regional doctor to talk with a remote nurse or a remote practitioner and manage a problem in a local context in a local facility,” he said. “[That means] no longer needing to rely on emergency medicine physicians in major metropolitan hospitals, but really developing that local context. That is a really exciting aspect of telemedicine – not only are we linking remote specialists but we are also linking clinicians together in the bush.
“We must still seek to understand its appropriateness, must seek to understand its cost effectiveness and must seek to understand its scope of clinical practice … but the fact is that I’ve been doing telehealth for probably 10 years and certainly Queensland Health has been doing it for longer than that. Clinical consultations at a distance is all it is and for our context it works very well.”
Keep it simple
Emerald Medical Group uses a range of technologies, all of them relatively inexpensive and readily available. It uses simple desktop PCs with over-the-counter cameras, and is enabled with both 4G and ADSL internet connections.
Telstra's 4G works surprisingly well, Dr McPhee said. It was made available in Emerald in mid last year, and when Pulse+IT spoke to him at the time, he was using a 4G dongle on his MacBook Pro to access his case notes and anaesthetic notes when he was in theatre.
“Hospitals have Wi-Fi but they don't like GPs getting onto it – it's like they have state secrets or something – so we use the 4G dongle for that and also ward rounds,” he said.
“Basically it means you can RDP back to your surgery database, do your case notes and you've got the ability to send your case notes back. What I've been trialling lately is using the 4G iPad for RDP access back into the surgery for after hours on-call. That seems to be working reasonably well. It's easier using iPads – you just flick them on and it's quite easy for people to remain connected and to talk.”
That said, he is still a keen advocate for the NBN. Before the change of government, Emerald was successful in its bid to build a GP super clinic, and while funding for that has been guaranteed by the new health minister, Dr McPhee said the NBN would be critical for its operation.
The copper wire network in Emerald isn't the greatest and the super clinic will be built out of town, so he is hoping the fibre network can still be hooked up.
In the meantime, 4G and ADSL are adequate for this practice's telehealth needs, which includes Skype to talk to private specialists and Cisco's Jabber to connect to clinicians in public hospitals on the Queensland Health network. Dr McPhee told the webinar that the ACRRM telehealth provider database had “tremendously enhanced” the ability to find and connect with a range of specialists.
The practice also uses store and forward to interact with Telederm, the ACRRM teledermatology service run by Brisbane-based dermatologist Jim Muir.
From a practice manager's perspective, billing and scheduling is not as difficult as many fear, Mrs McPhee told the webinar. She said it was originally planned to enable telehealth in each doctors' consulting room as that would be the most convenient, but that hasn't turned out to be the case.
“What we found was that the doctor wasn’t always ready at the same time that the patient and the specialist were ready,” she said. So the practice has set up two dedicated rooms for telehealth that can also be used for other purposes when not occupied.
“At the time that the consultation is due to start, one of our nursing staff takes the patient into that room, makes sure that it is working and that everything is good to go, and then as soon as the specialist is ready, the consultation can start,” she said.
"The doctor in our practice can come in when they are available and we’ve found this works really well because the specialist is able to come on as soon as they are ready and we don’t have that whole problem of everyone running late.”
The nursing staff are very comfortable with sitting in on the consultations, but the doctors are encouraged to also sit in as it can be a learning experience for them. They can also be called upon to assist the patient in interpreting what the specialist is saying and hear the specialist's advice for follow-up.
“We have found that a bit of nagging has been necessary to get telehealth happening at times, particularly into the Queensland Health network,” Mrs McPhee said. “We had one patient who was being asked to drive from Emerald to Rockhampton so that they could sit in on telehealth with a doctor in Brisbane.
“We thought that was silly as that’s a six-hour round trip to sit in on a conference by telehealth, so with a bit of persistent nagging, Queensland Health came on board and we ended up doing a three-way telehealth with the nurse in a clinic in Rockhampton, the specialist in Brisbane and the patient in Emerald. That worked really well and now that they have seen we can do it, it is happening more and more.”
Billing and scheduling
While Emerald Medical Group didn't get into telehealth for the money – Mrs McPhee said it was purely for the patients and helping them get the best care possible – it has been financially rewarding through the various telehealth incentives.
Megan Keaney, an acting assistant secretary and medical adviser with the Department of Health's medical specialist services branch, who also participated in the seminar, said that while the onboard incentives will cease on June 30, the regular telehealth MBS item would continue. She also clarified that the telehealth items would not attract the proposed $7 co-pay, should it begin as planned from July next year.
Mrs McPhee said the fact that there was funding available for both the nurses' and the doctors' time was important. “[The incentives] do make it easier to convince doctors to take time out of their normal consultations because they do get paid for it,” she said.
“Once they’ve done one or two they can see the advantages of it and they are actually going looking for more things that they can do by telehealth, because they get more feedback from the specialists and they feel much more part of the whole patient care than they do when the patient has to go away to see the specialist.
“Another thing that has been a major advantage for our practice is the fact that if we do telehealth there are people able to participate in the consultations that normally wouldn’t be able to for patients from a rural area.
“We are able to have school teachers come in and take part in the telehealth consultation with the paediatrician, extended family members are able to come in, and the savings in travel and time away from work all makes sense. We are very happy to keep on doing telehealth because it works really well in our practice.”
Dr McPhee said what he would like to see is telehealth normalised and made relevant to day-to-day clinical practice.
“With apologies to Forrest Gump, you need to keep it simple,” he said. “Certainly in Queensland Health there is a lot of very expensive video conferencing suites gathering dust on boardroom walls. What we need to do is deliver simple, effective means of consultation.
“We are nothing special and we are no IT experts. It’s really a matter of just doing it. For your basic face-to-face video consultation, it really works well.”
Dr McPhee said he was enthusiastic about the direction Queensland was taking with telehealth in developing a comprehensive process of joining public and private providers together.
“[And we are] starting to think about how we can support our allied health and our nursing professionals in the most rural and remote locations,” he said. “It’s a real watch this space.”
Posted in Australian eHealth