Two brain surgeons and a politician opened the Australian Telehealth Conference today here in Melbourne. It’s been a fascinating day, reinforcing my understanding of the strengths of telehealth as well as the barriers to implementation. I don't necessarily have a lot of new insights, but I’ve learned some new ways of viewing and articulating the issues.
Victoria’s Health and Aging Minister David Davis opened the day. A solid politician, who I sensed to be a little more hands-on in driving change than we are used to in New Zealand. (As another speaker observed, everyone has their own view of what the perfect health system looks like and to politicians that sometimes means that it isn’t a subject of contention at election time.) I learned about Victoria’s Health Innovation and Reform Council (HIRC) which made 12 recommendations on telehealth to the Victorian government, all of which were accepted. His Department has also successfully established a video conferencing connection service to ensure interoperability, something which is sorely needed in NZ where officials are still grappling with the problem of islands.
Adam Darkins, Chief Consultant for Telehealth Services in the US Department of Veterans Affairs, was one speaker I was especially looking forward to and a reason I decided to attend. He gave a comprehensive, information-rich overview of how telehealth has transformed the health care of US services veterans, quoting eye-watering numbers of video consultations and infrastructure – 1.8 million telehealth episodes a year across 150 service centres.
Telehealth has made homes and the community the focus of care for veterans nationwide. He stressed the need to standardise the way telehealth is done. Mental health is a key stakeholder as in NZ and the US has had a national Telemental Health Centre since 2010. Veterans Affairs takes a hands on role in its telehealth service including regular audits of each of its 150 plus sites.
Adrian Nowitzke, special health advisor, proved also to be a brain surgeon. He opened by challenging everyone in the room to identify themselves as a health sector leader. “In my neurosurgical practice I do zero telehealth,” he admitted. “I have made plenty of money and I am happy that my patients wait a month to fly down from Cloncurry to meet me - as a senior doctor I can talk about health outcomes and not worry about price – that’s for the admin people. We can’t let our senior doctors get away with that any longer.” Very honest stuff.
Banks have tellers no longer behind a screen - they come out from behind their counter and offer help, he noted. ”Imagine if you walked into a hospital and someone came over and asked how they could help you - In healthcare the lack of change is almost a badge of honour. We are missing the people power. We are so scared of giving the information to the people.”The problem, he said, is us as health care leaders and how we continue to do business, its not about the government.
He concluded with five requirements – take a holistic view of the system; focus on the end state; follow the patient’s journey; develop leadership at every level; and use a multi-stakeholder partnership to drive change.Nowitzke is an excellent speaker who we should bring to New Zealand at some stage.
A panel debate followed. Again Adrian came up with in my view the most profound points. Its about incentives, he said - money, penalties, and the like. We are silly putting a lot of money into doctors’ pockets so patients can come to them - instead the community should subsidise doctors to find innovative ways to communicate with patients efficiently.
Another panellist added that disruptive technologies displace the existing power groups. Doctors naturally won’t do things if they are not paid. Incentives need to be established around consumers – “I hate wasting time going to the doctor for a repeat prescription, despite the chance to read New Idea – I’d rather do it on line”.
There was a consensus that change can be of two kinds - Incremental change driven by incentives, or transformative change driven by shared vision.
In a breakout session about rural issues I learned about some great work going on in tele-optometry. It brought back memories of a personal experience a few years ago when I was spared the need for eye surgery by the accidental discovery of a long-forgotten test result from years earlier that showed my condition not to have changed for a long period of time. Opthomology equipment already incorporates much of the technology needed in telehealth so it is a shoe-in for early adoption, but needs adjustments to the government funding model before the benefits can be fully realised.
From Dr Ewan McPhee I learned about Queensland’s telemedicine emergency support unit – provided from within rural Queensland so as to preserve the understanding of a local context. He was another who argued that the system needs to start saying “no” to inappropriate subsidising of patients’ travel where telehealth could do the job more efficiently, but said telehealth first needs to be “normalised.” All it needs, he said, is a VC unit on the desktop, a good quality booking and admin system, and a willingness to allow nurses to take a bigger role in service delivery.
Afternoon speaker Dr Bastian Seidel from rural Tasmania was another highlight for me. My attention had been grabbed pre-conference by his assertion that by 2020 the majority of GP consultations will be by telehealth. I agree, but would not have been bold enough to say it in public. He described telehealth as a cottage industry within general practice. He questioned why there has been such poor uptake despite extremely generous government subsidies for leading edge users. His answer – protocols, Medicare and the colleges were all unprepared, Skype is considered unsafe, people are confused by statements from the medical boards. Two years into it doctors still have conversations about whether Skype is safe, he lamented. He pointed to a useful resource from the RACGP on telehealth.
Professor Anton Donkin from Healthdirect, an Australian government health advice service, spoke of the pragmatism inherent in rural areas compared to the regimentation in urban ones, as a reason to focus telehealth in rural Australia. He warned that huge consumer-led disruption is imminent. He demonstrated the new video telehealth service offered by Healthdirect (He gave everyone a good laugh by inadvertently switching his microphone to “mute” for the demonstration until an alert member of the audience pointed it out – been there, done that!)
He urged everyone to look for enough scale to be seriously disruptive rather than start more pilots with insufficient scale to make a difference. Design the system for consumers rather than doctors, he said – they want control of the time, place and device for health service delivery. Exploit existing consumer technologies and don’t spend a whole lot of money on them.
The day closed with a panel. Something of an anticlimax in my view, and from some of the questions and over-drink discussion I was not alone. The visionaries had left the room and the panel seemed to comprise conservative clinicians wedded to the status quo. One of the insights I gathered came from the floor – a CSIRO representative who noted that 60% of ED admissions in Australia are thought to be a failure of primary care, a reason for more monitoring of patients on an ongoing basis rather than episodically.
I do understand resistance from some clinicians. The problem is that as soon as youbring telehealth into the equation, you shine a spotlight on the fundamental weaknesses across the entire health system. It's the beachhead for a much wider, essential revolution in service delivery. Thatt adds weight to the case for fundamental change, not reduces it.
In summary: a valuable day. Australia has some inspirational visionary leaders in this space, but there is a very big group of clinicians unconvinced of the need for change. As I agreed with another NZ attendee afterwards, the clinical leadership in our country seems much more change-accepting. If I had to wager, I would bet on New Zealand getting telehealth established as mainstream before Australia despite the huge resources they are throwing at it.
I’ll report on day 2 tomorrow.