The PM and telemedicine: why has it taken so long?

From the first of July next year, Medicare will pay for telemedicine consultations for people who live in rural and regional areas and outer suburban communities where specialists are short, according to the Prime Minister’s announcement yesterday.

It’s not clear yet to Croakey whether these consultations will only be for medical specialists or whether allied health services will also be included. Nor have I seen anything on the dollars involved. (Update, more details here in the Australian General Practice Network release).

Nonetheless, this is smart politics, and not only because of the AMA’s quick endorsement. Politically, it served to remind us of the difference between hers and his on the national broadband network. “…this technology is about transforming how we deliver health care,” the PM said in reference to the NBN.

Policy-wise, some election attention to the health of Australians in rural and remote areas was long overdue.

Many will no doubt see the Prime Minister’s announcement as good news; others might wonder why the creaking, ageing health system has been so slow to respond to the opportunities of telemedicine, and to support new ways. [Telemedicine has been defined as “the use of transmitted images, voice and other data to permit consultation, education and integration in medicine over a distance”.]

A study published in the Medical Journal of Australia in 1997 (1997!), showing the benefits of tele-ophthalmology at Mt Isa Hospital, warned that the lack of Medicare support for telemedicine would impede its development.

It is very fashionable lately to bag bureaucrats for everything that is wrong with the health system, but they are not the only barriers to change. Professional interests also play a part.

Below are some snippets from a story I researched in early 2006 for Australian Rural Doctor magazine which looked at the potential benefits of telemedicine, and the barriers to its effective implemenation. I filed it to my editor under the title, “why the future is running late”. (please note that the people mentioned below were interviewed in 2006, their jobs and their views may have since changed).

Telemedicine is being used but…

A GP who was working in the central Queensland town of Clermont, Dr Mohammed Rahman, described a recent young patient who had not responded to his treatment and needed specialist advice. But he knew her family would struggle to find the time and money to make the 540 km round trip to the nearest paediatrician.

Just two days later, however, Dr Rahman, the girl and her mother were sitting in a consultation with Dr Michael Williams, the director of the Child and Adolescent Health Service at Mackay Base Hospital. Thanks to the wonders of modern technology – and the dedication of some committed telemedicine enthusiasts –  they were able to manage this without even leaving Clermont.

This was because Dr Rahman had booked his patient into the weekly videoconference clinic that Dr Williams runs for patients outside Mackay. Dr Williams established the telepaediatrics service ago after finding that travelling to Clermont and other towns was a relatively inefficient, exhausting way of providing outreach care.

Dr Rahman had nothing but praise for telepaediatrics. It provides him with timely support and advice, and his patients love it. “Most of the women here with kids cannot go to Mackay themselves as they have only one car and their husband needs it for work,” he says.

The service also saves Queensland Health by reducing the number of claims on its annual $30 million patient travel budget, and has encouraged closer links between specialist and primary care services, as well as between rural GPs and local child health nurses.

There was just one drawback – Dr Rahman was not reimbursed for his involvement as there is no Medicare number. “We are giving a service but we are not getting paid at all,” he says. In fact, the service costs him: during the hour that he spends organising and attending the consultation, he could see four or five patients at his clinic. “We are doing it out of our goodwill,” he says.

My article concluded that the uptake of telemedicine had relied largely on the goodwill of enthusiasts rather than systematic efforts to drive its implementation, which may explain why proponents say its uptake has been slow and patchy. Organisational and systems factors – rather than technological problems – are widely held to be the major barriers to its broader use.

***

Why so slow?

When researching my article, it became clear that there were few bureaucratic and professional champions for telemedicine.

One rural GP leader said that ensuring funding for the infrastructure, practice and ongoing maintenance costs associated with telemedicine would be more important for encouraging uptake than achieving Medicare billing numbers.

Others spoke of the need for telemedicine to be integrated into undergraduate and postgraduate training for doctors, nurses and allied health professionals.

One researcher mentioned “the rural telemedicine or ehealth paradox”. This holds that the places that stand to benefit the most have the least infrastructure and the least capacity in terms of people’s capability to use it.

Professor Peter Brooks, who was then the Executive Dean of Health Sciences at the University of Queensland, said the medical profession had been slow to accept its potential benefits. “Those who are pushing the ehealth banner need to be engaging more with rural doctors and really selling the message to them and showing the benefits to them of ehealth,” says Professor Brooks.

In future, Professor Brooks expected telemedicine would deliver patient education and provide specialist support to nurse practitioners and physician assistants in rural and remote areas. However, he conceded that the future may be slower to arrive than he would like: “Five years ago I probably would have predicted we’d be further along than we are; like all these things in life, it’s a bit slow.”

As part of researching the article, I also spoke with psychiatrist Professor Peter Yellowlees, who first  became excited by telemedicine’s potential in the late 1980s, when working in Broken Hill in New South Wales. He went on to establish telepsychiatry services in South Australia, and in 1999 became the founding director of the Centre for Online Health in Brisbane. When I spoke to him in 2006, he was running telemedicine projects at the University of California Davis in Sacramento.

Where once he was intensely frustrated by the slowness of telemedicine’s adoption, Professor Yellowlees says he has come to accept that change happens slowly in the health sector. “It takes ten to fifteen years for proven research methodology to produce widespread change in clinical practice,” he says. “It’s sad to say that but that’s how health systems are, there’s just a huge inertia to change.”

Professor Yellowlees also believes telemedicine has been slow to take off because its main beneficiaries are patients, whereas it is likely to cost the health system more because it is a time-consuming way of delivering care. “It’s a really good thing for patients,” he says. “But most health systems are set up primarily for providers…they’re not primarily focused on what the patient needs.”

Ultimately, he expects that telemedicine will become a routine form of medical care, providing home care across the board, not only in rural and remote areas: “Seeing your health professional on video will be one of the ways you can see them.”

But, given past experience, Professor Yellowlees does not expect his vision for the future to materialise quickly.

***

In conclusion…

Yesterday’s announcement by Julia Gillard may prove a step forward. But it’s only one of many that are needed on what has already proven to be a long, slow road.

Update: The RACGP’s Chris Mitchell welcomes the announcement.