Telemedicine: challenges and opportunities

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Telemedicine: challenges and opportunities ‘Telemedicine may be used to describe the process where information is shared between distant sites for diagnosis and decisions related to the clinical management of patients.’ Anthony C Smith Centre for Online Health, University of Queensland Level 3 Foundation Building, Royal Children’s Hospital, Herston Road, Herston, QLD 4029, Australia Tel.: +61 733 464 702 Fax: +61 733 464 705 [email protected]

10.1586/17434440.4.1.5

Expert Rev. Med. Devices 4(1), 5–7 (2007)

The tyranny of distance and disparity of specialist health services in regional and remote areas is a common challenge for health organizations around the world. The benefits of telemedicine are slowly being realized but its real potential continues to be hampered by quick-fix technological ‘solutions’, rather than a genuine investment in evaluative research and development. In general terms, telemedicine is the delivery of healthcare and the exchange of healthcare information across distances [1]. Other terms synonymous with telemedicine include telehealth, e-health and online health. Telemedicine may be used to describe the process where information is shared between distant sites for diagnosis and decisions related to the clinical management of patients. Telemedicine may also be useful for the education of patients and health professionals. There are two fundamental forms of telemedicine: realtime and store-and-forward. The first occurs when information is shared instantly in realtime. A common example occurs when medical advice is sought using a standard telephone. Videoconferencing is another example of a technology used for real-time telemedicine. The second method is storeand-forward or prerecorded telemedicine. In this instance, information is collected and sent using asynchronous techniques, such as email or the general post. Both methods have their advantages and disadvantages and, depending on the specific requirements of the telemedicine service involved, one or both methods may be employed. The telepediatric service in Queensland is one example of a service that provides principally real-time telemedicine consultations.

The service has developed steadily beyond its pilot phase and has been integrated into the mainstream service – benefiting thousands of children – throughout Queensland. Telepediatrics is carried out as part of a major research program at the University of Queensland’s Centre for Online Health (COH) in collaboration with the Royal Children’s Hospital (RCH) in Brisbane. Since the service began in November 2000, consultations have been conducted via videoconference for a broad range of pediatric subspecialties, including burns, cardiology, dermatology, diabetes, neurology, oncology, orthopedics, psychiatry and surgery. The telepediatric service is based on a unique model for the coordination of telemedicine [2]. A centralized referral center has been developed in Brisbane and is available to selected regional sites throughout Queensland. Telepediatric referrals are made easily by calling a toll-free 1800 phone number – a direct link to a telepediatric coordinator. Once a referral is made to the service, a specialist response is guaranteed within 24 h [3]. Telepediatric coordinators provide full technical support and manage all referrals made to the service. A range of communication technologies are used – including e-mail, telephone correspondence and videoconferencing. Approximately 90% of all telepediatric referrals result in a consultation via videoconference. Specialists receive notifications and reminders for pending clinics and, once they arrive at the center, the videoconference call is established by the coordinator ready for the consultation with the regional clinician (referrer), the patient and family.

© 2007 Future Drugs Ltd

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Smith

Videoconference clinics are conducted using digital tele- delivery. Specifically, it should be clear what the problem is, phone lines (ISDN) at a preferred minimum bandwidth of how telemedicine may help and how it will complement 384 kbit/s. Routine clinics are now scheduled 12 months in existing services. Even the most advanced equipment will lie idle if it cannot be advance, in a similar manner to a conventional outpatient department. Regional patients who need to see a pediatric neu- integrated effectively and efficiently into the routine work flow rologist, for example, can be referred easily to one of the weekly of clinicians. In addition, for telemedicine to be introduced succlinics available. One of the leading areas is post-acute burns cessfully into an organization, it is important that all sites care where almost 20% of all burns outpatients are now man- involved are resourced adequately in terms of staff, equipment, aged via videoconference [4]. In the context of our experience telecommunications, technical support and training. Why should health organizations support telemedicine? with telepediatrics, Brisbane-based specialists provide telemedicine services to genuinely support families who, as a conse- There are potential savings that will occur as a result of the quence, are saved the inconvenience and costs of travel away reduced numbers of patients traveling to see the specialist. For from home. In addition, the enthusiasm and commitment of example, most state health departments in Australia offer a regional clinicians have been fundamental to the success of the travel subsidy to reimburse regional patients for travel and accommodation costs directly related to appointments with a telepediatric service. A common misconception in the area of telemedicine is the specialist. In Queensland, the estimated expenditure for the patient travel scheme is approximately notion that the technology required is usually expensive. This depends on ‘One of the common mistakes in AU$30 million (£12 million) per annum. If even 10% of all outpatient the context of the application, the telemedicine is that managers appointments in Queensland could be type of information being shared (i.e., invest too much time and energy done using telemedicine, the potential text, digital images and video) and the speed at which transmission is into technological issues rather savings would be significant [2]. required. Telemedicine does not need than more imperative issues, such There are many factors that may to be expensive and, generally speakas how the technology will be influence the uptake of telemedicine. ing, prerecorded telemedicine relies introduced into an organization.’ In general terms, the advantages of upon cheaper telecommunications telemedicine are usually much more and equipment. One good example of a low-cost telemedicine obvious from the perspective of the patient. Telemedicine saves service is the Swinfen Charitable Trust (SCT) telemedicine pro- patients the inconvenience and personal cost of extensive travel gram that provides free medical advice to doctors in developing and time away from home [6]. The benefits of telemedicine are countries [5]. Users of the service only require an email account less clear from the perspective of the specialist. Reimbursement and internet access. The SCT also provides a digital camera for is one of the factors often blamed for the lack of uptake of telethe collection of still images, such as x-rays and clinical photo- medicine. In Australia, there is currently no government graphs. When clinicians in developing countries require spe- funded reimbursement scheme for general telemedicine consulcialist advice regarding a clinical case, they are able to send a tations (except for telepsychiatry), so the majority of specialists request to the SCT, which is then sent to an appropriate spe- are only remunerated for telemedicine consultations if they cialist. The SCT have access to more than 200 specialists who receive a salary from the hospital. However, it is not clear volunteer their time and expertise to support the service. The whether lack of reimbursement is a critical barrier or not. This benefits are mutual, with education and training gains for both is different to the USA, where patients can be billed for telemedicine consultations. referring and consulting clinicians. A major challenge for sustainable telemedicine programs is The development of a telemedicine service beyond the demonstration of feasibility is not a trivial exercise. A thor- related to funding. Despite considerable funds being directed ough review of the telemedicine literature gives a cruel towards the purchase and maintenance of telemedicine equipindication that very few telemedicine projects emerge beyond ment and infrastructure, there is very limited investment in forthe trial phase to become part of a mainstream health service. mal evaluation. Poor research funding equates to a lack of There are a range of factors that one could attribute to failed quantitative evidence to support telemedicine [7] and, ironically, attempts at developing a telemedicine service. One of the the lack of evidence is often considered the reason many organcommon mistakes in telemedicine is that managers invest too izations are reluctant to provide long-term funding for telemedmuch time and energy into technological issues rather than icine. Systematic reviews of telemedicine continually show that more imperative issues, such as how the technology will be the evidence for telemedicine is weak [8,9]. introduced into an organization. There are a number of Telemedicine services should be accessible easily, present no important logistical factors to be considered when develop- hindrance to the clinician and should complement convening a telemedicine service. An over-riding imperative is to tional outpatient services. If telemedicine facilities are not focus on the clinical problem first with careful consideration accessible conveniently, that is, in a central location within given to the significant organizational changes that are asso- the hospital, specialists are less likely to participate. It is also ciated with the introduction of a new method of service important that telemedicine sessions are organized and set up

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Expert Rev. Med. Devices 4(1), (2007)

Telemedicine: challenges and opportunities

by a technically competent coordinator, allowing the specialist to consult with the patient without any concerns related to the technology. A common feature of failed attempts at telemedicine is the lack of planning and research into the previous experience of others in the field. Too often, significant investments are made by organizations before they realize that their service has failed to achieve any significant telemedicine activity. There is a common misconception that, if you build a large telemedicine network, telemedicine services will perpetuate automatically. This outcome is never guaranteed. If you are planning a telemedicine service, review the literature and reduce your chances of the project becoming another expensive mistake. The COH convenes an annual international conference on Successes and Failures in Telehealth (SFT) for precisely this reason. We have developed a forum where people can learn from one another’s positive and negative experiences – both perspectives are equally important. In addition to the SFT conference, we also invest significant time and effort into the delivery of a range of undergraduate and postgraduate courses in e-healthcare that are designed to give health professionals both theoretical and practical experience in this developing field. These courses are important if we are to expect clinicians to use telemedicine as part of their routine practice. Take caution when promised that recent advances in technology will solve all of your problems in the healthcare sector. Technology is really only a small component of the overall equation and telemedicine planners should concentrate more on organizational change management strategies and the References 1

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Smith AC. The Feasibility and CostEffectiveness of a Novel Telepaediatric Service in Queensland [PhDThesis]. The University of Queensland, Australia, November 2004.

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Smith AC, Isles A, McCrossin R et al. The point of referral barrier – a factor in the success of telehealth. J. Telemedicine Telecare 7(Suppl. 2), 75–78 (2001).

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Wootton R, Craig J, Patterson V. Introduction to Telemedicine, 2nd Edition. The Royal Society of Medicine Press Ltd, UK (2006).

Smith AC. Telepaediatrics in Queensland. In: Telepediatrics: Telemedicine and Child Health. Royal Society of Medicine Press, London, UK, 25–39 (2004).

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mechanics of delivering telemedicine services. It is recommended that new services be piloted on a small scale and be developed gradually if proven beneficial. To conduct telemedicine successfully, it is important that all sites involved are well resourced; that is, personnel, equipment, telecommunications, technical support and training [10]. With careful planning, telemedicine has tremendous potential for the delivery of health services to regional and remote places. In Queensland, the telepediatric service is a good example. Since this service began in 2000, more than 4000 consultations have been conducted for 35 different pediatric subspecialist areas. In many cases, these families would have had to travel to Brisbane for a consultation that might have lasted for less than 10 min. Certainly, telemedicine saves families significant stress and inconvenience, including reduced time off work, absence from school and personal costs. Further information

For additional details related to the research and teaching programmes available at the COH, please visit the website: www.uq.edu.au/coh. Acknowledgements

The telepediatric service is funded by the Commonwealth Department of Health and Aging (Medical Specialist Outreach and Assistance Programme). Support is also provided by the Royal Children’s Hospital Foundation.

Swinfen P, Swinfen R, Youngberry K, Wootton R. A review of the first year's experience with an automatic messagerouting system for low-cost telemedicine. J. Telemedicine Telecare 9(Suppl. 2), 63–65 (2003). Smith AC et al. The family costs of attending hospital outpatient appointments via videoconference and in person. J. Telemedicine Telecare 9(Suppl. 2), 58–61 (2003).

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Wootton R. Recent advances – telemedicine. Br. Med. J. 323, 557–560 (2001).

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Hailey D, Roine R, Ohinmaa A. Systematic review of evidence for the benefits of telemedicine. J. Telemedicine Telecare 8(Suppl. 1), 1–30 (2002).

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Hailey D, Ohinmaa A, Roine R. Study quality and evidence of benefit in recent assessments of telemedicine. J. Telemedicine Telecare 10, 318–324 (2004).

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Smith AC, Bensink M, Armfield N, Stillman J, Caffery L. Telemedicine and rural health applications. J. Postgraduate Med. 51(4), 286–293 (2005).

Affiliation •

Anthony C Smith, Senior Research Fellow Centre for Online Health, University of Queensland; Level 3 Foundation Building, Royal Children’s Hospital, Herston Road, Herston, QLD 4029, Australia Tel.: +61 733 464 702 Fax: +61 733 464 705 [email protected]

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