Video consulting telehealth – from hospitals to the home and everywhere in between

Video consulting is a big subject, within a big subject (Telehealth), within a big subject (eHealth). Articulating what is involved can be like articulating the health system itself — not an easy task. This is because video consulting is just normal consulting with another travel option. The trouble is that most people’s horizons only extend to considering the ‘transport’ components (video conferencing), rather than all the end‑to‑end management and logistics that we take for granted under normal circumstances, and more besides.

For people who want do more than just hold a Skype video conference twice a year, comprehending the opportunities and issues involved is like watching stars come out — you see the one or two that most closely relate to your perspective, then a few more, and then you realise the sky is full of them. For example:

  • How do practices easily get set up with the most suitable technology for their needs?
  • How do we make it really simple to bring others in without them needing to be ‘set up’?
  • How do people find services and each other and connect to the right place at the right time using the right technology, without being in a dozen ‘directories’?
  • How do you create unique, individual video appointments for people?
  • How are sessions integrated from within existing systems and workflows?
  • How do you assess the practical capability of patients to do this from home?
  • What policies and procedures need amending?
  • How are multiple players and components orchestrated?
  • How do people know where, when, how, and with what to connect to their appointment?
  • How are consumers reassured about security, privacy, and the credentials of the clinicians?
  • How do practitioners manage medico-legal issues?
  • How do you leverage emerging eHealth systems and services?
  • How are private fees managed in excess of rebates?
  • Where do people go for local support?
  • How is end-to-end quality assured?
  • How are reporting, audit, and evaluation managed?

The trick is to view video consulting as just another travel option, and to think about the answers to these questions in terms of extending current paradigms where possible and then filling the gaps.

The current Australian investment in video consulting is around $620 million, matching our current investments in eHealth projects. Yet there is very little in the way of central building blocks, services, and governance by comparison. This is understandable given the history of the new MBS items — and the lack of bureaucracy is a good thing — however the ongoing predilection to simply invest in component parts of telehealth and not the ‘whole’ is of concern. There is no question that the current scatter-gun approach and the ‘retro-fitting’ of enabling components and information is making it difficult for people at the pointy end to decipher what is going on.

The problem with conventional operational experience

A senior figure in the eHealth sector said this year “if Australia can’t lead the world in telehealth, then we should give up”. Yes, Australia has a long history of telehealth within the public hospital sector, and yes, the clinical experience gained is invaluable, and yes we have a great opportunity to leverage all of this in the face of competition from overseas. Operationally though, this is a double edged sword. Conventional video consulting experience at an operational level has predominately been within single organisational and technical infrastructures using conventional video conferencing architectures that date back some time, such as those used by Queensland Health.

The ‘business to business’ (B2B) or consumer (B2C) nature of the primary health, home, and specialist environment is very different to this. As well as the inter-system and distributed nature of the challenge, the market is more likely to be informed by experiences with consumer video conferencing than they are with conventional technologies, and the former make more sense. The players are different and need to integrate video consulting as an extra dimension within existing and emerging information systems and other telehealth modalities. This is a green field opportunity where we can leverage our clinical experience but build new operational frameworks unencumbered by the restrictions of old world technology and thinking.

Multiple Inter-dependent components are required for success — the technology is only one

Multiple Inter-dependent components are required for success — the technology is only one

This is new ground from an operational perspective

There are many experienced people in the telehealth community, in the telehealth industry, and in the video conferencing industry who have shared a passion for the value of video consulting over the past 10-15 years. The financial ‘rains’ have sprouted a raft of instant video consulting experts and advice across the health system and the video conferencing industry.

However it is the author’s observation that virtually no one giving advice from government, academia, industry or the health sector actually uses video conferencing in the way that they are asking others to — i.e. daily in their own offices to talk with lots of different people in different organisations, including on an ad-hoc basis. This is indicative of the human, organisational, and technical issues involved — it’s not as straightforward as people think. If people do use video conferencing at work, it is most likely conventional technology and usually within their own or ‘joined up’ organisational networks — not what is needed. It is no wonder that sometimes it appears to be a case of the partially-sighted leading the blind.

Going forward, the Department of Health and Ageing have earmarked a further $47 million for telehealth training and adoption projects. How is this money going to be spent? What are we going to advise people, and how do we know that what we are telling them is right? In the author’s opinion it seems a little premature to be providing advice to others given the general lack of insight and cohesion that currently exists, and without the required central building blocks and services in place. Whatever happens, this work needs to be coordinated nationally and deliver a consistent message.

Later sections of this article list the current activities being undertaken by various stakeholder groups.

Before and after the consultation

Successful integration of video consulting is first and foremost a management, facilitation and work flow integration challenge, which simply cannot be achieved at a technical level alone, no matter what the vendor brochure might say. As I have said, buying a video conference system does not equate to successful healthcare appointments any more than buying a car does.

What happens ‘before’ and ‘after’ the consult is just as critical as what happens during it, and this is why Skype works so well. The main attraction of Skype — quite apart from the low cost — is that it is easy to get going, easy to find people, and only takes a single click to connect to the right place. Although Skype seems unquestionably here to stay, it is currently not scalable for many applications for a range of practical and privacy reasons, including the reasons highlighted by business-grade technology vendors. The fact that everyone needs to have an account and will forever be in your ‘buddy list’ is an issue in itself.

In any case, one system is not going to fit all. What we need is a common Skype‑like management platform for healthcare that is as easy to provision as Skype, but which has more specific functionality like scheduling and services directories. It would exist separately from the infrastructure layer so people could use their own video conference technology, and it would not require participants to have an account.

The Victorian experience

In Victoria, the public hospitals are divided into multiple networks with separate organisational and technical infrastructures, and there is no central ownership or control over any of the infrastructure. There has also been no Government telehealth department and little funding for telehealth management over the years. From inception, state-wide video conference event management has been forced to facilitate inter‑organisational participation using peoples’ own video conference infrastructure and be sustainable from an operational and financial perspective.

As volumes of participation grew and became both national and international, an ‘open’ management model was developed that identified 12 local and central ‘roles’, and provided context based information and functionality to these geographically dispersed people.

This experience of providing overarching central building blocks and services closely matches the challenges that Australia now faces more broadly, although it has gone under the radar because the programs are not part of a single publicly funded project.

Key lessons have included the need for a core business focus on overall outcomes and independence from the component parts. Also important is separating the user interface and business management functions from the infrastructure layer. This means multiple video conference technologies can be accommodated, and users get a consistent experience as the underlying technologies get easier, cheaper and become ubiquitous.

Enabled clinical service providers are the key

People who live and work outside metro areas don’t need convincing of the benefits derived from video consulting. Unlike isolated patients or healthcare professionals however, the benefits are not as obvious to the mostly metropolitan based clinical service providers. For these people with already full schedules, the convenience, ease of use and effectiveness of the video consultation process is at least as important as the financial incentives.

The solutions must include sustainable business models from a practical as well as financial perspective. The technology has to be accessible in the same place as the service provider, and the appointment must be as easy to agree to and as rewarding to participate in as a physical encounter. When a clinician notes their next appointment is via video it must be a single click to join it — as simple as calling in the next patient listed in their electronic appointment book.

Infrastructure and practice set up advice

The Royal Australian College of General Practitioners (RACGP) Implementation Guidelines for Video Consultations In General Practice Version 2 are as good a place to start as any for practical advice. These are an evolving set of practical guidelines, which have now had quite a bit of input. Combined with the newly released Standards for General Practices Offering Video Consultations, which is an addendum to RACGP Standards for general practices (4th edition), there is a lot of useful guidance, although arguably there is too much information to be easily absorbed, and a more suitable delivery medium such as a web video or an online course could be considered.

The guidelines categorise the technologies as per below, and give an indication or the pros and cons of each. Note this list is roughly in order of price, access, and convenience, not quality or functionality. The often used term ‘high end’ has become a misnomer, as software‑only solutions now deliver the same high definition quality and functionality that would have been referred to in this way:

  • Web browser video conferencing
  • Computer software video conferencing
  • Tablet app video conferencing
  • Desktop video conference appliance (dedicated unit)
  • Video conference room appliance (dedicated unit)
  • Immersive video conference solution

They also give practical guidance on areas such as bandwidth, which is another misunderstood topic that means different things to different people and is steeped in wisdom that is past its ‘used by’ date.

In a pre-NBN world, bandwidth challenges relate as much to access as they do to capacity, and the capacity debate is as much to do with the volume of concurrent usage as it is the demands of a single video conference, even a high definition one. Smaller practices have different needs in this regard to larger or multi–location practices.

The upload speed of a connection is just as important as the download speed for video conferencing, as this affects the quality of what you send as well as what you receive. Thanks to modern video conference technologies, dedicated links are arguably not required in many situations, however the type of Internet link and service quality remain important factors. In some areas and for some practitioners an ADSL2+ connection provides good enough quality and thus no new service is required, although it is a good idea to check that your practice has a suitable data plan to avoid excess data charges. There are limited options available above ADSL2+ or cable. The pricing gap between consumer and commercial services can be significant and while the latter tend to offer much better reliability and quality with higher upload speeds, the download speeds are often slower than available with consumer offerings.

Later sections of this article list several organisations where advice about Internet connectivity options may be sought.

Technology, interoperability and interconnectivity

Everyone has different needs and challenges, and it is important to be clear where interoperability (different systems being compatible like fax machines), and interconnectivity (different systems being able to connect to one another across networks), are important and where they are not. For example this is an important consideration for public hospitals where there is a lot of existing video conferencing equipment and a need to communicate across the rest of the health system.

The current interoperability problems with Secure Message Delivery (SMD) are not a good yard stick for video consulting. Like email, a secure message can arrive at any time without notice and you might receive messages from multiple disparate systems at once. Standards are important to avoid the need to have multiple systems and monitoring each of them for a message. Video consulting is not like that — you only need to be in one video conference at a time and there is a level of prior arrangement, even if it is only a few minutes.

Standards are important however and exist in commercial grade technologies, although native calling between these and FaceTime or Skype seems a long way off. This challenge is being worked on feverishly worldwide and arguably what we do in telehealth in Australia is not going to speed this up.

In the mean time there are multiple scenarios and approaches which are listed below. In some of these we need to be careful not to achieve interconnectivity at the cost of overall quality and limited functionality because the technologies are forced to communicate at the lowest common denominator.

Interoperability and interconnectivity are not factors in many scenarios

There are many scenarios where this is a non issue, for example, where all parties are working within a single management and technical platform, e.g. the forthcoming Medibank Health Solutions Online Care (American Well), Skype, Lync, or a public hospital network.

Similarly, in many environments and as part of the call initiation, it is quick and easy to download the video conference program or ‘app’ that the originating party wants to use if it doesn’t already exist, e.g. WebEx, GoToMeeting HD Faces, Vidyo or Lifesize. It is already commonplace to have multiple video conferencing software products on a computer or tablet. Getting people together then is more of a management challenge than a technical one. Of course this doesn’t work as well if the people need to create an account in the video conference system to connect.

People using standards based video conference systems can connect via the Internet today, although this often requires a level of user knowledge, and some conventional technologies don’t handle the Internet very well. In the future, technologies will deliver the required video quality using only Internet access and a web browser. Flash based solutions and services like Google Chat can do this now, but arguably without the video quality, and people still need an account.

The exchange approach

The exchange approach lets people connect using a diverse range of standards and non standards-based technologies over different networks. Everyone dials in to a central ‘exchange’ which has links to all of the networks and houses all of the technologies. The exchange then acts like a central, multilingual interpreter so that everyone can see and hear each other.

Examples include the proposed state health department cross-jurisdictional National Telehealth Infrastructure Service (led by the NT Department of Health), BlueJeansNetwork, and the Vantage Network Operations Centre.

Video conferencing exchanges make sense in some scenarios as an interim solution while native interoperability remains an issue, although they are expensive to deploy.

The telephony approach

The aim of the telephony approach is to achieve the same level of reliability, quality, device independence and interconnectivity that we expect from the telephone network. Today, this approach suits people who want end-to-end quality assurance and service level agreements within a business grade environment. Right now as a stand alone solution this only works using dedicated network connections from a single carrier, so interconnectivity and open access remains a problem. In the future, people will be able to call between different carriers using a common dialling plan and standards like SIP and E.164 numbers. This does seem some way off as the technical and financial peering agreements between carriers are yet to be worked out. Most telecommunication companies are engaged in activity relating to this approach and it is the basis of a soon to be released telehealth offering from Telstra.

The business layer management approach

When Australia had different rail gauges, Queensland bananas still somehow made it by train to Victoria. This was a triumph of end-to-end logistics management rather than native connectivity. Today, every Thursday night, 80 different video conference systems on different networks located in hospitals all over Australia are connected to a single video conference event. This is achieved by keeping a record at the business management layer about who has access to what technologies, plus information about each technology and how to connect to it. The management layer then passes information to the relevant people and technologies about when and what they need to do to connect.

For example, a specialist at the Alfred Hospital using Vidyo can click on a video appointment with a specialist in Townsville hospital using a Tandberg system. The fact that this travels through five technologies over three IP networks is transparent to the participants.

Peer to peer over the Internet in the future

Right now, standalone, standards-based video conference systems can interoperate with each other assuming there are no connectivity issues.

In the future, software-based technologies like Skype or FaceTime may be able to natively interoperate taking advantage of the substantial bandwidth that will be available. We seem a long way off this happening seamlessly in a B2B and B2C environment although Microsoft’s recent purchase of Skype may influence this.

Government and health sector activity

There is some great telehealth work going on but you would be forgiven for being confused or for questioning the amount of duplication, given the size of our population and the overall lack of experience of actually achieving the outcomes we seek. There are at least five health sector or government organisations offering similar practical advice, including the Department of Health and Ageing itself.

What is needed is a single, aggregated source of up-to-date, coherent, consistent, and authenticated information that everyone agrees on, and that health service providers can consume in multiple levels of detail. It needs to be democratically editable but moderated, and deliver categorised information about available vendor solutions matched against standards and guidance. People need to see the information in a snapshot, and then drill down in more detail if they are interested. The information needs to be endorsed by all stakeholders as an objective assessment rather than individual opinion or a regurgitation of the vendor’s marketing. The Australian College of Rural and Remote Medicine (ACRRM) are working on a product inventory that seems like it might head in this direction.

A brief synopsis of telehealth activity the author is aware of is outlined below:

Australian College of Rural and Remote Medicine National Telehealth Advisory Group

The Government has funded ACRRM to develop a TeleHealth Standards Framework and a range of support materials to assist medical practitioners, patients, and health facilities to understand and appropriately utilise video-based telehealth services for rural and remote communities.

ACRRM has partnered with specialist and nursing colleges, peak Aboriginal, rural health, and telehealth associations, and the Royal Flying Doctors Service, and their work includes a telehealth product inventory and an advisory service.

Australian Information Industry Association

AIIA are founding members of the Australian Medical Telehealth Industry Alliance (AMTIA), and have a health task‑force that includes many of the leading infrastructure suppliers in this space.

Australian Medical Telehealth Industry Alliance

AMTIA has been brought together recently by founding members RACGP Oxygen and representatives from the video conference industry. The scope of the AMTIA appears to be growing beyond its original focus on technical solutions and interoperability, and the organisation is expected to release more details soon.

Australian Health Practitioner Regulation Agency

AHPRA has released Draft Guidelines for Technology Based Consultations that represent guiding principles rather than operational advice.

Australasian Telehealth Society

ATHS is a predominantly academic and public hospitals based society which provides telehealth policy recommendations, advice, and advocacy. Their second annual meeting will be held 1-2 December, alongside the Queensland University Centre for Online Health Successes and Failures in Telehealth conference.

Department of Health and Ageing

DOHA are funding a range of initiatives and projects, some of which are mentioned throughout this article. DOHA has also set aside $47m for video consulting training and support, but the details of what the training will cover, and how it will be managed, are yet to be released.

The DOHA Telehealth Advisory Group consists of representatives from across the heath sector. The MBS Online website contains very comprehensive and well presented information about the MBS item numbers and related matters.

DOHA also recently released for comment two practical guidance documents which appear to have been written by different people. The content of the Guidance on Security, Privacy and Technical Specifications for Clinicians document displays a remarkable disparity in experience compared with the Telehealth Technical Standards Position Paper, which seems to be on the right track. Considering its objectives, the Guidance paper actually falls a long way short, in the opinion of the author.

Health Informatics Society of Australia

HISA ran the Rural and Remote Telehealth conference in Cairns in July this year, and included a telehealth event as part of HIC2011 in partnership with the ATHS.

Medicare Locals

Medicare Locals are slated to play a key role in providing local support and training for video consulting.

National E-Health Transition Authority

NEHTA is in the process of scoping what its involvement in video consulting should be. They reportedly have received an estimated $1 million additional funding for this purpose, and to provide input into related DOHA projects.

In the opinion of the author, once NEHTA gets to grips with the entire breadth and depth of the video consulting space (as opposed to simply the video conferencing part), it will recognise a great opportunity to leverage its existing workplan for the benefit of video consulting without re-inventing any wheels.

National and state based general practice networks

GP Victoria provides a good summary of telehealth on its website, and GP NSW has published two presentations providing information and practical advice.

National Health Call Centre Network / Health Direct

In partnership with key stakeholders, NHCCN are developing a National Health Services Directory to support eHealth in general, and this is expected to include video consulting and contain details of providers of services that offer access in this way.

Royal Australian College of General Practitioners

RACGP Implementation Guidelines for Video Consultations in General Practice Version 2 are an evolving set of practical guidelines that have received quite a bit of input. This, combined with the Standards General Practices Offering Video Consultations, which is an addendum to RACGP Standards for general practices (4th edition), provide some sensible and practical advice as a starting point. RACGP also provides an advisory service via a call centre.

Conclusion

There is a lot happening in this space and rightly so — the enormous health outcome, economic, and social potential is well documented. Telehealth in general has been touted as the ‘get out of jail free’ card that can address rising health care costs and the challenge of the ‘ageing tsunami’. It’s also pretty convenient and popular with consumers.

The government has done a good job in providing the raw materials for the health system to work with, and should be congratulated for its vision. There is a lot to do, however, both practically and from a communication perspective. ‘I see what you are saying’ has a whole new meaning in a video conference but people need to experience for themselves the massively increased value that visual communication delivers compared to the telephone.

There seems general agreement that overarching national building blocks and services are needed which bring together the business layer, the governance, the health information and workflow systems, and the video conference infrastructures from an operational perspective.

The question is how long will it take us to get this right, and how much more money will we waste viewing the component parts of this jigsaw in isolation to each other? Simply seeking technical solutions to what is a management challenge does not work.

We know from our own experience, and that of leading telehealth programs such as the Ontario Telehealth Network, that operational solutions must include an overarching management component with an independent core business focus on overall outcomes rather than component parts. To put this multifaceted jigsaw together, you must know what you are doing, and you can’t be one of its parts.

Chris Ryan
Principal Telehealth Consultant
Attend Anywhere
This email address is being protected from spambots. You need JavaScript enabled to view it.

Chris Ryan is the principal telehealth consultant at Attend Anywhere, an Australian company with a long history of facilitating the sustainable inter-organisational use of people’s own video conferencing technology to exchange health services. Coming from a rural health background, Chris has played a key role in the adoption of video conference telehealth since arriving in Australia in 1995.

Declaration of interest

Chris Ryan is the principal telehealth consultant at Attend Anywhere, an Australian company with a long history of facilitating the sustainable inter‑organisational use of people’s own video conferencing technology to exchange health services.

Attend Anywhere provides technology independent consulting focused on the people, process, technology, and service integration issues involved, as well as a range of central building blocks and services.

Attend Anywhere does not supply video conferencing technology, but does have an overarching management platform based on the Victorian distributed management model. The platform lets people find services and each other and attend on-demand or scheduled appointments and events, using the technology available to them.

Chris also consults to many organisations, including Monash University, the RACGP (where he worked on the RACGP Implementation Guidelines for Video Consultations in General Practice), and is a member of AIIA, ATHS, MSIA, HISA and the AMTIA.

Posted in Australian eHealth

Comments   

# Bob Bull 2012-11-16 21:02
You have nicely articulated the common challenge with ICT-enabled changes to healthcare service delivery - technology is seen as a "silver bullet". While the technology barriers to support B2B and B2C are decreasing, the business integration is anything but "plug and play". The hump cost for entry into videoconference based Telehealth continues to be a major barrier for individuals and organisations. Videoconference equipment vendors are not helping by continuing to offer terminal equipment beyond the means (and needs) of most organisations (one of the few computer technology based markets that does not conform to "Moore's Law"!). This along with the changes to clinical work practices results in the relentless cry for subsidies. This scatter gun approach to incentivisation will result in some short term success, but is typically unsustainable and does not scale. The solution in the medium term lies in an end to end model that provides service assured inter-connectiv ity (your "Exchange' model) supported by telehealth consulting, business integration and training services to minimise the clinical impact.

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