Wednesday 4 January 2017

Telehealth: An important tool for patients and medical professionals alike.

[Image: A woman (me) with green hair is wearing a red dress, black stockings and red shoes. She is sitting, looking to her left, in her electric wheelchair on the grassed verge on the side of a rural road. Behind her is a fenced paddock with a large dam and green pasture. In the distance are a line of trees and farm buildings.]

I live three hours from the city in a rural area of Australia. I love the lifestyle. The quietness. The fact that most things I require are within a five minute car ride. Even the beach is only 20 minutes away. But I don't enjoy the fact that all my specialists are three hours away. I was recently interviewed by
Carly Findlay for the ABC about disability, health and being a rural patient and one of the things I spoke about was the need for medical professionals to embrace telehealth

It's not the first time I have written about how fantastic telehealth can be from a disability and rural perspective. Back in November 2015 (back when I first started this post and then promptly forgot that I had indeed started this post) I commented on my FB wall about the joy of having a Skype appointment with my Urologist:

"Oh how I love telehealth. Yesterday I had my urology Skype appointment. We reviewed my meds and my symptoms, discussed my bladder diary, put together a plan, and booked in a review. It was all bulkbilled ($0 out of pocket for those OS). An email arrived 10mins later with charts and appointment information. All sorted.
The ability to Skype with my specialist saved:
*A 6hr round trip to the city
*Parking fees
*Petrol costs
*Buying lunch or coffee in the city
*A day off work for my husband
*Getting dressed.
*Stress on my body with associated payback from such a big day. Especially after being in ED Friday.
*No worry about organising Freyja (our dog) or my son.
*No steps to climb (her office isn't accessible)
The list goes on.
I wish more doctors and allied health specialists (my specialist dietician does Skype, but it costs $90) would use Skype. As a rural patient whose specialists are all in the city (and too rare/weird that I can't just see any cardio/neuro/gastro/urologist) it would save so much physically and financially.
Not all appointments can be Skyped (I had seen my urologist in person twice before as there were hands on parts to do), but for those that can, why can't more implement such a system?"

But it is not just we who live in rural or remote areas that could potentially benefit from increasing telehealth options. For individuals who live in a major city, but through disability or illness are unable to easily mobilise, are primarily in bed, or have mental health issues which impede leaving the home, telehealth would provide an option to engage with their treating doctors or allied health therapist without commensurate physical and emotional cost. With improved access to health care, there are often better long term health outcomes, less frequent hospitalisation and a decrease in excess disability. And whilst I am primarily concerned with improved health outcomes for my fellow patients, financially, decreased hospital admissions and a reduction in excess disability makes sense for a government constantly banging on about a budget emergency and need to cut costs.

State of play in Telehealth in Australia: the Statistics.

Medical Benefits Scheme (MBS) Online Statistics provides information on the uptake of telehealth  up to 1st July 2011 - June 2016.

Since it's inception in 2011, 475,545 Medical Services have been processed, for 144, 400 patients by 13, 815 providers. Of these, Specialist providers accounted for 320,677 services and GPs 152, 106.

The number of services provided has increased since 2011 from 26,049 (2011-12) to 150,634 (2015-16). 

By specialist type, Psychiatry has the greatest proportion of providers using telehealth at 794. With reference to common specialities utilised by Dysautonomia patients, the figures are as follows: Cardiology 226, Neurology 158, Gastroenterology and Heptology 211. And my Urologist appears to be one of the 142 in her speciality willing to use telehealth.

As you can see from the table below rural and remote patients are the largest consumers of telehealth. 

 Services by Patient Remoteness Area (RA) - claims processed as at 30 June 2016
RA Name
Major City
Inner Regional
Outer Regional
Very Remote

Lived Experience of Telehealth in Australia

At present the system is ad hoc with some medical professionals willing to embrace telehealth and even work out bulk billing options (this is often not widely advertised, despite it being a highly desirable option for many patients), to those who refuse outright to use any form of telehealth, be it Skype, phone or email. While others offer the option, but the cost (such as the example above with my dietitian) can be prohibitive for people who are often amongst some of the poorest in the country.

"People with a disability face a significantly higher than average risk of poverty, with 27.4% (620,600 people) with a disability living in households below the 50% poverty line in 2009-10 (as noted in the previous report). A large proportion of people with disabilities have household incomes in between the 50% and 60% poverty lines, so that the risk of poverty rises to 44.5% for the 60% line (based on 2009-10 data)." (Australian Council of Social Service (ACOSS) Poverty in Australia 2014)

Whilst financially the challenge of any medical interaction either in person or via another medium can be prohibitive, the physical and mental stress associated with travelling for an in person appointment with practitioners who refuse, or are reluctant, to employ telehealth can be large. For example: a couple of years ago my GP had to prescribe me significant pain medication just so I could drive the three hours (six hours return not including the appointment and associated wait time) to see a specialist who then didn't touch me, asked about three questions and then ushered me out the door with a "Lets not change anything and see how you go. Come back in six months". Such an appointment could easily have been conducted over Skype, the phone or email, and the pain, exhaustion, and symptom escalation which wiped out the following week, could have been avoided.

There will always be concerns that necessitate in person appointments (I would also suggest that, where possible, in person 1st appointments are a great idea for both doctor and patient to get to know each other and develop rapport), but for those where there is no need for a "hands on" appointment or only minimal investigations required eg bp and hr checks there should be alternatives available.

I would love to see rural and remote medical centres provide a dedicated room where local patients could have their Skype appointments with distant specialists. Such a room could be supported by a specialist nurse who can both facilitate the technical side of the process and provide basic assessments as necessary, eg measuring bp and hr. Some 1.3 million Australian homes (ABS 2014-2015) have no access to the internet due in part to the exorbitant cost of even basic internet connections here in Australia (Australia recently came last on a World Economic Forum's list of affordable Internet) a factor which hits hard on disabled households who, as already noted, are already more likely to be living in poverty. As such, a system as suggested above, whilst convenient for many, would also be a vital service provision to those more disadvantaged members of our society. It would also be of use for those who are unfamiliar with this form of technology and/or mode of communication, potentially providing emotional and educational support throughout the process.

There will always be patients who will require ongoing in person appointments for a whole host of reasons. This should be facilitated as best as possible by relevant health authorities (eg here in Victoria there is the Victorian Patient Transport Assistance Scheme (VPTAS) which provides some reimbursement for travel more than 100kms one way or, if necessary, accommodation costs, for a medical appointment). Identifying those patients that require the added support in person appointments provide is part and parcel of the treating doctors basic practice (one they already do to assess things such as, how often reviews are required, or who needs a follow up phone call, those who need more supervised medication management etc). Assessing, and where possible addressing the factors, medically, socially, financially and psychologically that prevent patients accessing care, accessing care appropriately, or impede ability to self-manage certain aspects of their condition, or in this case, use telehealth, will aid in maximising health outcomes. A win for patients and medical professionals alike. (Note: Increasing health literacy across the whole community would also increase the number of patients who could utilise telehealth.)

Telehealth is not an option for all patients or all medical professionals. It will not solve all the medical access issues faced by rural, remote or mobility-challenged patients. And there are costs and educational processes that need to be put in place on both ends. But telehealth represents an important, new and evolving tool that can be added to the arsenal to improve practice and health outcomes alike.  

Like involvement in social media, it is now an area of service that many patients are actively seeking out. There are doctors like my Urologist who see telehealth as an important tool to help rural patients and a professional time saver for her where she can schedule multiple short review appointments in a smaller time frame. Others that even see the value of offering International Skype appointments for disorders that are rare, poorly understood or serviced around the world (like Dysautonomia). When I see some embrace and understand the role of the technology in health care so easily, it makes me wonder what we need to do to encourage others to make the leap.

I hope one day telehealth appointments will be commonplace. And seen as an important tool in the overall management options whose benefit is clear to patient and clinician alike.