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Hello, I'm Norman Swan.
Welcome to The New Bush Telegraph -
Telehealth For Rural And Remote Practice,
coming to you on the Rural Health Channel.
On behalf of everyone, I'd like to acknowledge
that this program is being broadcast
from the land of the Wangal people of the Dharug tribe,
traditional custodians of the land and part of the Eora nation.
We acknowledge their elders, past and present.
Telehealth is nothing new.
We've been using the telephone for as long as it's existed
for health information,
including sending data long before there were computers.
What's new are telecommunications networks
that allow videoconferencing
and the transmission of detailed images
and of course now, the availability of Medicare rebates.
Over the last year or so,
over 20,000 patients and 6,500 clinicians
have taken part in telehealth consultations
which have saved time, money and smoothed care in many instances.
But that's a tiny proportion of the total business in health care,
so the potential is still enormous,
and that's what this program is about -
what's stopping some practices from putting telehealth in place
and how to overcome those barriers.
We'll hear from our panellists of their experiences using telehealth
and how their patients are reacting
to seeing their doctor on screen rather than in person,
and what telehealth has meant to them and their health-care teams.
We'll also help clinicians watching
who don't know where to start, and I assume that's a few of you.
This is a professionally accredited program
from the Rural Health Education Foundation,
broadcast on the Rural Health Channel.
It's also being broadcast simultaneously
via a live, online webcast and on NITV.
As with all our live programs,
we want to hear your questions to the panel, or comments.
You can get in touch by phone, text, email, fax or by computer.
The details are on your screen now.
Emails can go to:
You can text us on:
Or you can phone us on:
We'll put you on air.
Does anybody use fax anymore?
If you do, you can fax us on:
If you're watching via the webcast on your computer,
you can type your questions or comments into the Live Talk box
and click, Submit.
We're taking questions and comments live
throughout the panel discussion,
so send them in as they arise from now on.
For those of you on computer,
it would interesting to know who's interested in telehealth,
so let us know what group you're in:
Click the answer on your computer, and we'll get the results shortly.
Let's meet our panel.
Ewen McPhee is a rural procedural general practitioner,
practising in Emerald in Queensland.
He wears many hats, including being VMO in Obstetrics
at the local hospital,
Deputy Chair of the Central Queensland Medicare Local,
immediate past president
of the Rural Doctors Association of Queensland
and a member of the Statewide Rural Clinical Network
for Queensland Health, the latest Clinical Network in Queensland.
Yes, there's a lot of good work to be done
in rural and regional Australia.
- Welcome to the program, Ewen. -Thank you.
Ewen's also been working as part of ACRRM's
TeleHealth Advisory Committee.
When do you have time for your day job?
Well, you give a job to a busy person, I suppose,
if you want things done.
Professor Isabelle Ellis is a nurse and a midwife
who has worked for my years in rural and remote Australia
as a clinician, educator,
health-service manager and researcher.
Isabelle was the inaugural telehealth coordinator
for the Kimberley region of Western Australia,
and is currently working for
the Tasmanian Department of Health and Human Services
to establish telehealth services in the north-west of the State.
Isabelle is Chair of the University of Tasmania's
eHealth Research Centre.
- Welcome, Isabelle. - Thank you, Norman.
You've moved from one remote area to a slightly less remote area?
It doesn't feel less remote at times.
Don't let people in Burnie hear you say that.
How true.
Tasmania has a lot of very beautiful, remote areas,
so it's a very special place to be.
- Plenty of potential for telehealth? - Absolutely.
Carol Bennett is the Chief Executive Officer
of the Consumers Health Forum of Australia,
the peak national organisation for health consumers in Australia,
leading its work to ensure a strong consumer voice
and consumer participation in the health forum.
- Welcome, Carol. - Thank you, Norman.
CHF works to achieve safe,
good-quality and timely health care for all Australians,
and therefore sees telehealth as an important mechanism
to achieve this, especially for those living in rural and remote areas.
I need to make a declaration that my wife is Chair of the board,
so Carol needs to behave.
Associate Professor Sabe Sabesan
is the Director of Medical Oncology
and Senior Staff Specialist in Townsville Hospital, Queensland
and Clinical Dean of Townsville Clinical School
at James Cook University.
- Welcome, Sabe. -Thank you.
Sabe's been involved in telehealth for the last six years,
and is a passionate advocate for its wider use.
You must have seen some changes?
Many changes, through the gentle persuasion of colleagues, mainly.
You're fed up telling people about the benefits,
you just want to tell them how to do it now.
Yeah, exactly. We've been doing it for six years,
and now I can see so many other potentials.
I want people to come up with new models of care
to help all Australians.
We'll talk about those later.
Di Thornton has been nursing for a long time
in both rural and metropolitan areas,
despite how young she looks.
In fact, she prefers to live and work in the rural setting.
- Welcome, Di. - Thank you, Norman.
For the past - mm - years, Di has been the Executive Officer
and Director of Nursing
at Pinnaroo Soldiers Memorial Hospital
in rural South Australia,
and in her spare time is a farmer's wife.
You're another one who's got no time for the day job.
Di is a passionate advocate for the use of anything technological
that will improve access
and reduce travelling for rural people.
Proving that this technology works, we also have joining us
via videoconference from Western Australia,
Associate Professor Angus Turner.
Angus is an ophthalmologist based in Western Australia,
is actively involved in delivering specialist eye services
to remote and Indigenous communities,
with a particular focus on the Kimberley and Pilbara regions.
- Welcome, Angus. - Thank you very much.
Angus is also involved in research,
working on a number of research projects
at the Lions Eye Institute in WA,
focusing on service delivery to remote and Indigenous peoples.
Welcome to you all.
So, let's get the results of poll question 1.
Consumers are 4%.
7.5% for GPs.
35% nurses.
And we have no Aboriginal
or Torres Strait Islander health workers -
this is on computer, watching online.
20% specialists
and 32% managers.
So, that's who's watching, at least by computers.
Let's go to our next poll question.
For clinicians or health professionals watching:
What are your answers to those questions?
Ewen, how long have you been using telehealth?
I've been using it for about 12 months quite regularly now.
NORMAN: What does regularly for you mean?
At the moment,
we do 5 to 10 to 15 consultations by telehealth every week.
Are you in a single-handed practice?
No, I'm the principal of a small-group practice,
predominantly a teaching practice with a number of GP registrars.
- Are you all using it? -Yes.
Everybody's converted?
Everybody's converted, but being the boss...
- You have to lead from the front? - Also a bit of prodding.
Let's go through the technical stuff,
because the rules have changed in what's available. Who's eligible?
First, how do they define telehealth?
- It's only videoconferencing? - Yeah.
At the moment, it's a simulated face-to-face consultation.
The MBS item numbers are specific for non-admitted
and not for ED patients either.
And the patient has to be located outside RA1.
The patient and the physician
have to be at least 15km apart.
But also, it does include
residential aged-care facilities
and eligible Aboriginal
medical services as well.
So, yeah.
The people that can do this are
specialists, consultant physicians, psychiatrists,
but also medical practitioners,
midwives, nurse practitioners, practice nurses,
Aboriginal and Torres Strait Islander health workers.
The Medicare - there's quite a lot of items.
There are. In my situation,
I've got a practice manager,
my lovely wife, who knows
the item numbers very well.
It's very practical inasmuch as
you can look at the MBS online,
look at the item numbers specific
to your own circumstances.
There's 17 for specialist services,
including some new items,
and 23 for patient-end services
occurring in the consulting room,
the patient's home or in an AMS
or an aged-care facility.
How long did it take you to get up and going?
We didn't take long at all.
The technology is freely and easily available.
We needed a good internet connection
and a reasonable camera.
What really helped us was having specialists on board
who were keen to get up and running.
NORMAN: Somebody to talk to. - That's right.
Angus, how are you using it?
I've been using it based in Perth
as an adjunct to the outreach ophthalmology services
that we have throughout the Kimberley and Pilbara.
Most places, we only attend as an ophthalmology team,
about two to four times per year.
We've been using it in between times for follow-up,
and also sometimes preceding a trip to start some management.
That means, when we see the person in real life,
we've already started something and can see how it's going.
It's also being used with quite a few emergency calls
that come in relating to a red, sore eye
or some problem from a GP up in the north.
Interestingly for our purposes with the eye,
optometrists have actually been very keen on the technology
and have used the service more than anyone else.
However, they're not actually part of the Medicare rebates
or any of the telehealth changes.
So it will be interesting to see how this area changes in future.
They're doing it for love?
They are doing it for love,
and hopefully that shows that it's quite helpful for them,
because they are regionally based optometrists.
For example, a town like Karratha
only has one optometrist full-time.
That person sees a lot of medical problems
different to perhaps an optometrist in an urban area.
The support offered through telehealth is really beneficial.
It takes quite a bit of trust.
If you've got somebody, say, with a queried detachment,
you've got to make sure the optometrist is looking properly.
It's true to a degree that the important thing for eyes
is having a good picture.
We need a picture of the front of the eye but also the back.
The technology for taking photographs
of the back of the eye is truly extraordinary.
It changes every six months.
I can't keep up with the new cameras.
Many of them are getting cheaper and more accessible.
We're discovering that the smart phones,
the computers in our pockets, are taking superb images of the eye.
It's an exciting area for ophthalmology.
We'll come to back to some issues in a moment.
Let's get the answers to poll question 2
about whether you're already using telehealth.
13% of you say yes.
17%, less frequently.
And 70% no! Well, stay watching.
We'll see if we've convinced you at the end of the program.
We'll try and find out why.
Before we go on, let's go on to another poll question
for those watching on your computer.
What are the views of
your patients about telehealth?:
Obviously, these are questions
for clinicians whose patients
are actually using
videoconferencing and telehealth.
We'll come back to those answers in a moment.
Carol, you've surveyed consumers about this?
We have. We've talked to consumers all around the country
about telehealth and the benefits that they see
resulting from using that service.
A recent poll we did indicated that
90% of the people that responded to the survey said
that they were aware of telehealth and its benefits.
50% of those had either used telehealth
and found it beneficial
or would use telehealth if they were offered the service.
There's a lot of scope for
consumers to be made aware of the benefits.
But certainly there's a lot of interest by many people out there
to use these services.
The stories that we hear
from rural and remote areas in particular,
where people have say, diabetes,
that can be managed really well through telehealth
in rural Western Australia, to the woman in Queensland
in a rural area who has breast cancer,
who needs ongoing management and follow-up,
through to the toddler in rural New South Wales,
who might have eczema
that requires quarterly visits to a specialist,
but can actually be managed quite well through telehealth.
What do you think the role of the consumer is
in getting more clinicians to take it up?
Consumers can drive demand.
If they can see the benefits and how that can help them
and if they know people that are using these services
and getting the benefits and they understand what that is,
they can drive demand.
The benefits come in terms of cost savings to consumers,
the time saving and the convenience.
When people don't have to go to the city,
the costs involved in the travel, the accommodation,
but also cost in terms of work time lost,
having to take other siblings out of school
to get them to these appointments
and all of the inconvenience that goes with
having to get to the city for appointments
when it can be managed well through these services.
You're using telehealth, Di,
in the most acute situation imaginable.
We don't have resident GPs in Pinnaroo.
If we have emergencies like an MVA, which we had last week -
a motor-vehicle accident...
We had a fellow that we managed via the videoconference
while MedSTAR, our retrieval team,
were in flight, on the way to us,
and we had the intensive-care specialist
on the other end of the line.
It's like he's in the room with you.
It's such a good support.
He can manipulate the camera, he can see,
he can zoom in to the monitor, he can do whatever he needs to do
and leave us to do the physical stuff
and say, 'How about you do that? Let's look at that next.'
It's great. It works like he's in the room with you.
So this saves lives?
It does save lives.
NORMAN: It's the difference between something and nothing.
- And it's good quality. - Yeah.
It's just that you don't have somebody to put in the difficult drip for you.
We've got pretty good at that, actually.
And who funds that?
The Telehealth Unit is being funded by the State
through Country Health SA.
What else are you using it for?
A myriad of things.
Patient-wise, we've used it for consultations with oncologists.
When we've had people at home in the community
who are too sick to travel to see their oncologist,
we use it for meetings.
We've used it for training.
We've used it in mental health
for some of our consumers having cognitive behavioural therapy,
linking up with one of the psychiatrists
at Rural and Remote.
The options are endless.
No problem finding a specialist at the other end?
No.
Let's go to your answers to poll question 3,
which was, what are the views of your patients?
64% of you say they like it.
Nobody thinks it's too impersonal.
About one in five think
they can't understand the person at the other end
and one in five, technical problems get in the way.
Sabe, has that been your experience?
My experience has been mixed,
but in terms of patients, I agree with the poll.
The majority of them like it
because of the benefits Carol was talking about.
NORMAN: But it's not perfect?
It's not perfect because it's the same as face to face -
if we interview 100 patients
who have been to a face-to-face clinic,
you're not going to get a perfect satisfaction rating.
Carol would say, ifonlyyou would interview 100 patients
that have been to your clinic.
Certainly, the patient perspectives
are the same as the polls.
The technological aspects,
it happened early in the piece, five years ago,
but now everyone is familiar with the technology
and how it operates.
That's not an issue anymore.
Describe your model of care, what happens.
It's extraordinary - there's been a transformation.
For us, the model evolved over the last five years.
That reflects the fact that you start simple
and then build on the experience and make it complex.
When we started, five years ago,
every new patient had to see us face to face in Townsville,
then for follow-up, we could use the videolink.
The first chemotherapy, they had to have it in Townsville,
the simple ones could be done in Mount Isa
and the complex ones had to be done in Townsville.
After a couple of years, we did patient-satisfaction surveys,
and they liked it and trusted the system.
We said, OK, they still have to come and see us
but they don't have to have the treatment in Townsville.
A couple of years later we realised,
we don't even need to see the patients
if patients don't want to see us.
I'm sure that's about trusting the people on the ground,
the service providers - general practitioners, nurses -
who are there to provide that support
that you don't feel you have to see the patient
for every consultation.
That's an interesting point about telehealth.
That's exactly what we are trying to achieve,
not just seeing patients.
I've found in the last five years,
by shifting specialist services to rural and remote communities
through telehealth, you are able to expand the scope of practice
for rural practitioners.
That means they are upskilled.
They are general nurses, general doctors, general allied health,
but they are getting upskilled to the point
that the providing end will trust the system.
That will come across when you talk to the patient.
I could now proudly say
that whatever service we offer in Townsville or Brisbane
is available in Mount Isa.
I tell the patient up-front, even if you come to Townsville,
same treatment, this is what you will hear.
Do you want to come or are you happy to be there?
I think it's fantastic
that you actually ask consumers what they think of the service,
then tailor it according to their needs.
That generates confidence amongst people likely to use the service.
That's what I found with confidence-boosting also.
With all the government fundings,
the tertiary sector tends to absorb it.
The key message here is, look after the remote side
so that is capable of receiving your specialist services.
Recruitment and retention in other towns might be better
because people feel more supported?
Exactly.
So you've got a rule now
that first consultations are done by telehealth?
Exactly that.
For Mount Isa, because we have a full, comprehensive service,
they are seen anyway.
But for the 20 other small towns,
what we found was, a lot of to-and-fro travelling happens.
Patients come to Townsville and realise they need a scan,
a particular blood test.
If you see them first time on telemedicine or telehealth
and found that certain things needed to be done,
if they have to come to Townsville,
they are all coordinated.
It becomes a team online.
Who's taking notes with the patient?
That's again an interesting question.
We expect that the remote end and the providing end take notes.
My assumption is that whoever provides the service
takes full responsibility for the care.
I work with the assumption
that if there's any other problem with continuity of care,
at least the providing end continues
with the continuity of care.
Who's the providing end, you or them?
For medical oncology, it's the specialist service we're providing.
Is it a nurse or a doctor at the other end?
That again depends on the complexity of the case.
CAROL: And where you are. - And where you are.
If there's no doctor, you can't get a doctor.
In my practice, for about 20% of patients, I don't demand a doctor
because a lot of small towns are one-doctor, half-a-doctor,
fly-in-fly-out-doctor towns.
I don't want to put extra pressure on them
by expecting them to be there.
How does it work with Aboriginal communities?
Aboriginal communities -
we've just published an Indigenous perspective
on telehealth in Australian Rural Health, in the October issue.
The summary was that the perspective is the same
as non-Aboriginal, non-Indigenous populations -
same demands, same issues, same travel, same people.
So I treat them the same.
- They welcome it as well? - They welcome it.
NORMAN: There are added benefits for Aboriginal communities.
The main thing I really enjoy
about telehealth to Aboriginal communities
is that when I see one patient,
there's at least 8 to 10 family members coming with the patient.
NORMAN: Crowding in. - Half of them are young people.
When I'm talking about...
So the natural support system comes with them,
which is impossible when they come to Townsville.
One patient brought their traditional healer with them,
so I was able to work with them
and give them a comprehensive package.
The other day, I was doing a consultation.
That's the good thing about traditional Tandberg systems.
You can show the CT scans.
You're talking about the proprietary brand
of videoconferencing system.
Yes. I was showing them where the cancer was.
I could see all the family members were getting interested in the case.
They said, 'How did the cancer happen?'
I used it as an opportunity to talk about the impact of smoking
in lung-cancer genesis.
I found that the community gets really involved in
Indigenous telehealth consultations.
If they had to come to Townsville,
one nervous escort will come with them
and the family will miss out on the whole thing.
They get second-hand, third-hand information.
I would argue that that's a much better service.
If you think about what Sabe has said
about the family getting education
and also about the practitioners being upskilled,
that's got to be better for the communities using it.
Than giving it to the airlines.
There's an issue though
where you've had five years to set it up.
A lot of general practitioners are looking at this and thinking,
how do I initiate it?
With the Queensland health infrastructure being embedded
in quite powerful systems,
have you found it more difficult to get GPs online
in Queensland health facilities?
- Actually... NORMAN: Just to explain,
Queensland works differently, as in all cases, from other States.
There is more emphasis on local hospitals,
medical superintendents, who are GPs...
A lot of your consults
would be to the hospital rather than to GPs' surgeries.
Yes, certainly that has been an issue in the firewalls.
We're trying to buy systems that cross-talk to...
You were talking about Polycom and things.
That aside, whenever I was talking to GPs
and they were talking to me...
Most Queensland GPs had admitting right to the hospitals.
They would go to the hospital and use the system.
But for people who couldn't go to the hospital, I cheat the system
and go to the clinical-school computers and use the Skype.
That way, I can still provide some follow-up consultations
and second opinions for GPs who cannot afford the big systems.
Can I ask - when it comes to using the GPs' services in the hospital
or in an emergency department or the systems you describe,
the government Medicare benefits and incentives
don't seem to quite apply there.
In the last 100 cases
that we've audited for the ophthalmology ones,
only 3%, three cases, actually had a provider
naturally using the Medicare rebate.
The other people work in emergency departments
or optometrists' or Aboriginal-health clinics,
where they're salaried.
It's an interesting problem
with the incentives not quite reaching the target audience.
There's a question here from Natalie Wischer.
'My name is Natalie Wischer. I'm a credentialed diabetes educator
working in the area of telehealth.
Currently I'm not funded to provide
an online telehealth service to my clients
unless it's with a specialist such as an endocrinologist.
Just wondering what progress has been made
towards allied health professionals
such as diabetes educators
being eligible for government funding and rebates.'
Isabelle, do you know?
At the moment, unless you're a nurse practitioner,
you're not covered for telehealth consults
using the Medicare rebate.
Paradoxically, a diabetes educator who's a nurse would get rebated.
Yes, but not a diabetes educator
who may be a nutritionist or something else.
That's one of the big problems that we have in Australia
with the expansion of telehealth services -
it doesn't cover all the professions.
It doesn't cover ophthalmology.
NORMAN: Optometry, you mean.
It doesn't cover a lot of allied health services.
We *** on about diabetes all the time.
Surely it's time diabetes educators get on board.
Absolutely.
That will take a bit more lobbying
from the rest of the health team.
We do need them as part of our team.
Also, to be fair to the system,
in face-to-face life, there's no rebates for diabetes educators
and allied health.
If you're comparing face to face with telehealth,
government might argue...
NORMAN: Get over it and get on with it.
We actually started well before the MBS items.
The first 600 consultations, we did for service only.
But you were saving $2,000 a transport.
It's only the last year or so, since July, we were getting paid.
Before that, it was a service delivery.
I just want to go to poll question 4,
which is asking you:
Let's hear what your answers are
to that question.
And let's go to South Australia,
where we'll hear from a patient and a specialist
about their experience
of forming an effective doctor-patient relationship
using videoconferencing.
Hi. My name's Michael, and I have an mental illness.
The type of illness I have is schizoaffective disorder,
which effectively means I get depression, anxiety
and mild schizophrenia, or I hear voices.
All of that means I need to see a psychiatrist regularly.
The reason I need to see one regularly is I can relapse
and I can recover and I can relapse.
It happens quite quickly sometimes.
I've been seeing Michael for about five years
as his psychiatrist.
He has previously had admissions to hospital, but in recent years
we've been able to avoid him coming to hospital
through intervening fairly regularly
with telehealth consultations.
I think that's very helpful for Michael and his family.
Michael is very comfortable with telepsychiatry.
We have a fairly relaxed approach,
where he describes some of his recent problems.
We review his medication
and talk about strategies for his improvement.
I've found that seeing Dr McKenny on the telemed,
I've been able to build a really good relationship with him
at a professional level from their side of things
and from a patient-to-doctor relationship for me.
There's still the confidentiality,
there's still the fact that what you say
doesn't go outside the room.
That's from South Australia.
We've got a question online -
'Is telehealth a good option for mental-health patients...'
From Shelly Reynolds from an Aboriginal medical service.
'..with issues who need one-on-one support
with a psychologist or psychiatrist?'
Ewen, what's been your experience?
We've had a lot of experience in the past with psychiatrists
talking with our patients in our rooms.
It's worked extremely well.
There's been no difference with the rapport and the relationship
and also the level of understanding of the patients
with regards to their treatment programs and follow-up.
It's been very well received
and enthusiastically received by people.
Do you think there's a consumer issue over confidentiality, Carol?
The important thing is that
consumers who are using these services
have an opportunity to understand what the service provides
and what the limitations of the services might be -
concerns about the technology
and the privacy limitations, for instance,
and that they feel comfortable,
they feel as though they're committing to doing something
for their best health-care interests
and that they're comfortable with the parameters around that.
If there's good, informed consent,
it has real potential to provide enormous benefits to consumers
who are really committing.
Tele mental-health services
have been the longest-running telehealth services in Australia,
going from the 1990s,
and have probably been the highest-researched services.
They are very, very well accepted by consumers.
They've really led the way in actually teaching the rest of us
how to build a patient rapport, and then how to consent patients
so you're not putting that consent up-front.
I might put this to Angus.
We don't consent patients when you refer...
If I were to refer somebody with a cataract to you, Angus,
I don't do an informed consent.
Why should there be informed consent for telehealth?
As has been mentioned,
the telehealth situation is a bit new.
The awareness of what is happening
is important for the patients to understand.
They need to be aware
of who's listening in to their conversation -
anyone else in the room, standing perhaps behind the camera
or a medical student, et cetera.
I always ask patients whether they're happy to proceed.
For my area, it isn't actually quite the same.
Unlike an oncology consult or a psychiatry consult,
I don't have a chance to look at the person's eye myself.
I do have images which are good.
But I do verbally talk to the patient
about the advantages of telehealth
but the fact that
I'm not able to use the equipment myself on their eye,
and are they happy to proceed.
Have you got any data on quality of care and safety
of a telehealth consultation in ophthalmology?
No, we don't.
It's an area that's being researched right now.
NORMAN: What about anecdotally?
Have you missed a retinal detachment, for example,
or something like that?
Fortunately, anecdotally, these sort of things haven't happened.
We've been very much on the cautious end.
A quarter of the patients I've seen on the internet or telehealth,
I've followed up in real life.
We've relied on good technology,
but occasionally, we'll say, 'That image is not clear.
I can't see what's happening, and I'm worried about this.
You need to come to Perth, in my setting.'
In three cases, people were still flown down
for an urgent check-up.
For routine care with eyes, the images are extremely good,
just as they are with the ears, for telepathology.
It really allows the specialist at the other end
to get a great view, and can ask the local practitioner.
There's a huge difference between
someone trying to describe on the phone what they see on the eye,
saying, the black bit next to the white bit has a spot on it,
compared to an image, where I can instantly see the picture.
It's a huge advance.
The area of retinal screening for diabetes
has a long history in telehealth, far before this rebate.
It's a bit like psychiatry.
That has been studied extensively with large, systematic reviews
showing that a photograph taken without dilating the pupil
by a health worker as opposed to a specialist eye-camera person
is good enough and acceptable for screening for diabetes.
That area is continuing,
even though that's a different part of telehealth
to what we're discussing today.
It's not the chatting bit on videoconsultation.
It's more, storing an image and sending it later.
Ewen, on the quality of care,
if I had cancer, I'd want to be examined by a medical oncologist,
to lay their hands on me.
If they're not laying their hands on me,
I'd wonder whether I was getting the same quality of care.
There will always be people that want hands-on.
The question is whether we're missing anything by not.
With telehealth,
you have to think about your scope of practice
and what's appropriate.
Telehealth is teamwork between the specialist and the GP
or the nurse.
You have to be logical and consistent about this.
There are times when it might be appropriate
for that person to go away.
You always have to have a fallback position
with telehealth.
I would be concerned if we were going to say
that telehealth is always going to replace
a face-to-face consultation.
It is reasonable that it's a first choice.
When you're thinking about whether to send the person away
or to have a telehealth, say, can I do this by telehealth?
But you have to have a fallback.
If there's a poor-quality reception,
if the specialist is not happy that
they're completely comfortable with what they're seeing,
it is essential that you have a way
of getting that patient to see the specialist.
I would add that the patient has a key role to play
in that decision.
As a partnership with the practitioner,
they should be involved in that decision
about what they're comfortable with -
whether they want the hands-on approach
or whether there's another approach they're comfortable with.
Maybe medical oncologists don't bother examining people,
they just do tests.
SABE: It's actually true.
When it comes to cancer management,
especially the follow-up ones,
after you finish your treatment for, say, breast cancer,
the investigations don't make any difference.
Research shows that.
Even in face-to-face, we don't do bone scans, CAT scans.
It's simply examining the lymph nodes
in the supraclavicular area, axillary, the breast examination
and maybe chest and abdomen.
Any registered medical practitioner
should be able to do that, and we will trust that.
That happens, even in the tertiary sector.
Half the patients are not seen by the specialist.
That's the power of telehealth in a way -
that you can screen the people
that are going to need to go away.
You get some information about what tests would be essential
for that person to have done.
I had a person that needed to see a haematologist.
The haematologist just had to look at full blood-count pictures
and say, 'This is what we're going to do.'
If we'd needed a bone marrow,
we could have organised that and whatever.
Traditionally, I would have had to send that person 1,000km
to see the haematologist, wait a couple of months
to get an appointment, then come back.
Two months worth of worrying to look at a full blood count.
So, it's a very powerful medium.
That's where Sabe's example of initial consultations
is really good.
You've got the referral from the GP, then you do the consultation.
You're a specialist. If there's something extra you want
that hasn't been done in the blood test,
the patient hasn't wasted a 300km, 400km, 500km round trip
or a couple of thousand.
They can get done before they have to see you.
I want to go to the results of question 4, which is -
if you're not using telehealth,
what's the main thing stopping you?
Over half of you said you don't know where to start.
Very few of you think there's a technology problem.
Very few of you think you're too busy to do the planning.
Quite a few of you don't know who to link to.
And patients don't like it.
We'll come back to, you don't know where to start.
But who to link to, Isabelle, that does seem to be an issue.
How do you know if there's a Sabe on the other end?
Aha. That is a very big issue.
For specialist services around the country,
whether they be oncology services,
wound-care nurse consultant,
nurse practitioner or any other type of service,
we haven't established very good registers of those yet
for people in general practice.
There are some being established
through the Royal College of General Practitioners,
where you can go and find out who's available.
Within most departments of health,
there are specialist services who will let you know
that they're running telehealth services such as Sabe's.
But a lot of people have no idea if they're working in GP land.
No, I'd challenge that.
I think you go local.
You pick up the phone, talk to your local specialist and say,
let's do a telehealth.
NORMAN: You push the issue? - You push the issue.
Say, I've got patient X, and they need to see you fairly quickly.
Would you mind doing a telehealth consultation?
Give them some options, Skype or whatever,
something really simple for the specialist to understand.
(Isabelle laughs)
The other thing to say is that ACRRM -
College of Rural and Remote - provide a database,
which is very well populated now.
I have very little difficulty getting the information I need.
It doesn't have to be somebody in the catchment area of Emerald.
- You could go to somebody in Perth. - Yeah, Perth or Melbourne.
SABE: One of the things...
On that point, there's a really distinct advantage
to having a provider that knows the area
and has the potential at least to be able to follow up in person
or arrange a follow-up back in the city.
So, obviously not always possible.
The kind of service Sabe has is fantastic,
because there's continuity.
Whereas, just calling an oncologist in Perth
to talk about that catchment area
is potentially a lot more difficult.
ISABELLE: And it sets up really big problems
within the health system,
because specialists should be providing services
to a particular group of people.
If you're trying to link a range of services
which might include allied health and specialist medical services,
it's got to fit in the system.
Let's flick through a few questions
before we come to where to start.
We haven't got a lot of time left,
and we need to get to the technical stuff
about what to do and how to do it.
A maternal and child-health nurse from Victoria, Lael Ridgway, asks,
'I'm interested in using telehealth
to support well-child checks in remote areas.
Can you address this area in your discussion?' Isabelle?
Yes, absolutely, you can do well-child checks.
But are you going to be Medicare reimbursed?
If you're not a nurse practitioner
or you're not working in a general practice
as a practice nurse, no, you won't.
But you can definitely do well-child checks
and be having the child with you and linking, no problem.
Janelle from the Australian Medicare Local Alliance
asks how useful telehealth is if people move between towns.
In Aboriginal communities, people go to see relatives and so on.
SABE: I'm glad you asked that question.
At least four or five Aboriginal patients I had,
they moved from town to town.
The first time,
I saw a patient in Mornington Island with his family.
It was lung cancer, so it just needed a chest X-ray.
I said, 'I need to see you in six weeks for the chest X-ray',
which can be done in a small hospital.
He said, 'I'll be in Doomadgee in six weeks.'
I said, 'OK, I'll see you in Doomadgee.'
He said, 'You're stalking me and following me!'
Then the next trip was in Mount Isa.
It was fantastic for that particular patient.
People don't have to restrict their lifestyle or their cultural needs.
The other issue is
the personally controlled electronic health record.
We have to be very conscious that that's coming.
That's really going to empower keeping that continuity going.
For people dealing with telehealth,
it's that shared record
between specialist and primary-care provider
that will be so important.
There's a question I don't really follow, it's Janelle also,
asking if one of the reasons for low uptake
is that GPs don't have their own
independent telehealth item numbers. Is that true?
GPs do have their own telehealth item numbers.
They're time-based, based on the amount of time you spend
in consultation with the specialist.
I think there's a general reluctance because it's new
and people don't necessarily see the value in it.
It's all a little bit too hard.
It's about getting over that hump
and realising it's a tremendous service for your patients,
but also a great educational opportunity
for yourself and your registrars.
I teach GP registrars.
What better way to learn about oncology
than to sit in on a patient consultation -
your patient speaking with an oncologist
about the condition
and the registrar learning about that process at the same time?
Do you have your practice manager set up that link for you,
or do you do that straight from your office?
You have to have some structure around it.
There has to be someone within the practice
whose responsibility it is to facilitate that.
It often can't be the doctor,
because the doctor is too busy or gets called away or whatever.
NORMAN: Or is a klutz.
EWEN: Or a klutz, yes.
There will be somebody in the practice
whose responsibility it is to facilitate that.
Would you call them your clinical champion?
- I call them my wife. (Laughter)
Let's get down to brass tacks now.
We've convinced the 70% of people watching who haven't got it
that they're going to do it.
What do they do tomorrow morning?
I'd go down to *** Smith and buy a camera.
Talk to Telstra or Optus or whoever dealer you've got
about getting an internet connection
if you haven't got one already.
NORMAN: You need broadband? - Yes.
- You don't need broadband? DI: No, you don't.
We haven't got broadband in Pinnaroo
and we probably won't for the next seven years.
- We still manage quite well. EWEN: I'm sorry.
You've got the intensivist guiding you from a dial-up connection?
Uh-huh.
NORMAN: Do they sound like Stephen Hawking or what?
You'll have to ask them. They think they go quite successfully.
Their feedback to us afterwards is that they go quite well
and they feel as though they've made a difference.
EWEN: That's ISDN. - Yeah, that's ISDN.
We've got an ISDN one in A&E
and we've got a digital one in one of our rooms.
So thatisbroadband, in fact, better than broadband?
NORMAN: It's not really a dial-up connection.
EWEN: No, dial-up is... ISABELLE: Too slow.
Too slow.
You do need some form of broadband.
Then you just need to pick up the phone.
You're talking like an enthusiast,
like somebody telling you about your first computer -
if you just do this, this and this... No.
This is the enthusiast who likes tinkering under the bonnet.
Tell me exactly what you do.
I'm a Luddite. I'm frightened of this technology.
I don't know where to start. Give me the practical stuff.
I've never been into a *** Smith store
to buy anything apart from a DVD.
If you want advice and support, there's the College of GPs,
the College of Remote Medicine provides support.
Most Medicare Locals have telehealth officers
available for consultations
and advice on how to get this up and running.
There's plenty of support out there.
90% of GP practices are computerised
and are having IT support in the practice.
They're used to having IT support.
Get your local IT guy, who's probably 22 years old,
and say, I need you to set this up for me.
I need to be able to talk to these guys on the other end
and make sure that I look good. They can do that for you.
You buy a camera, you've got your computer.
How do you make the connection?
It's all about software
and both the specialist end and the GP end talking to each other.
A lot of that is just negotiating with the specialist
what software they're using.
We do a lot of talking with the Queensland health facilities,
and we use Polycom.
NORMAN: That's hospital to hospital?
No, that's GP to hospital.
So that's via a web browser,
or you go to a special web-based program?
It's an expensive Skype. You pay for this.
It's like WebEx.
You can use FaceTime on your iPad.
None of these are complicated things to use.
ANGUS: Or Skype. ISABELLE:Or Skype.
How often do you use Skype, Angus?
I've tended to use Skype for 70% of the last 100 cases.
The 30% that weren't on Skype
were using, in a hospital setting, something called Scopia,
which is another videoconferencing software.
For optometrists and GPs in a small community
or in Aboriginal-health clinics,
Skype has worked very well
because people are familiar with it, patients understand it.
We talk about the fact that we're using an internet connection
and say that this has had some security issues
and we don't really know what those are.
We mention that at the start and say,
are you still happy to talk about your eye?
I can understand other areas of medicine
may be more sensitive for people,
but people, with their eyes, are quite happy
'cause you can see them anyway.
The other simple thing is really,
find out who else is using telemedicine around your area.
Even in Townsville Hospital in the last 12 months or so,
a lot of people knew we were using, so they'd sit in with us.
Then they'd say, oh.
I'd say, that's what I've been telling you.
It's not scary once you do it, so do it is the thing,
and learn from doing it.
Do you have to register for telehealth with MBS or just start?
No, just start doing it.
I want to get another question from you,
which is checking back on a question I asked earlier:
There's the killer question.
Ewen, what resources are available?
You've mentioned some of them.
I've mentioned the College of Rural and Remote Medicine's
ehealth site and the RACGP telehealth site.
There are a lot of guidelines, fact sheets,
but also provide databases and directory support.
The Medicare Local network has got telehealth offices
specifically tasked with assisting GPs and specialists
and getting up and running.
SABE: A lot of specialist colleges
are now beginning to join with ACCRM
to come up with this kind of advice
for people who want to do telehealth.
ISABELLE: The Nursing Alliance is working as well
to make sure they're working with
ACCRM and their colleges.
NORMAN: Isabelle, we've got a question
from Terrie Ivanhoe,
a nurse practitioner from Tasmania, no, Western Australia.
How does it work for nurse practitioners
to be able to claim Medicare?
ISABELLE: Hi, Tez!
We're just establishing that at the moment.
It depends where you work.
You can certainly put in your claim
if you're working in family practice.
If you're working in a hospital, it doesn't work.
If you're in a family practice...
NORMAN: If you're community-based. - Yeah.
What if you're working in a rural hospital
which is breaking down the barriers
and nurse practitioners go out into the community as well?
Which increasingly, in rural areas, is happening.
They're not just working in the hospital environment.
It depends if they're working in the emergency department,
working as an outreach from the emergency department,
such as Hospital In The Home.
NORMAN: They'd be salaried.
Yeah, if they're linking with the general practitioner.
It very much depends on where you're working
and how that arrangement is paid for.
That could be seen as double dipping.
If you're getting paid by the government
and then you get a Medicare rebate...
NORMAN: Or cost shifting, as some would say.
Briefly, what other things are you using it for,
now that you've got it?
What about education, team-building, things like that?
We use it for meetings.
We have our monthly senior-nursing meeting for our region.
We do that via videoconferencing.
We use it for education.
All of my staff who are doing online upskilling
to be an enrolled or even a registered nurse
will use videoconferencing for some of their lectures.
In the last 2.5 years,
while I've been studying to be a nurse practitioner,
I Skyped every night with my study buddies
from the University of Queensland.
I wouldn't have survived without doing that.
You could use it for just about anything.
Telenursing and transferring expert nursing
like chemo nursing,
we're piloting in a town called Ingham,
to be able to do simple chemotherapy in small towns.
You use the technology, you have chemo nurses in tertiary areas
or larger centres
and guide the non-chemo nurse how to finish the chemotherapy.
We're using it for renal nursing, wound-care nursing
and a whole range of nursing specialities.
Karen Gifford, an OT from Western Australia, asks,
and we've kind of answered that already,
'Is there a database of participating medical providers?
Short of phoning each specialist,
how do we know who can offer telehealth?'
Remind us of the answer.
The Australian College of Rural and Remote Medicine
has a provider database on their ehealth website,
which you can find online.
The issue, I guess, for me,
is the opportunity with education training,
but also support for allied health professionals
is something I'd really like to see.
How we advocate and move forward in doing these wonderful things
is really important.
Just where we've got to so far since telehealth started
in the late 1990s has been extraordinary.
We've been asking for Medicare rebates
and trying to get over the barriers for ten or so years.
We're making extraordinary inroads into those problems.
NORMAN: That's fantastic.
Let's get the answers to that question -
if you aren't already using telehealth,
has watching this program made a difference?
100% of you say yes!
Well done. Right answer.
(Panel laughs)
We'll have to redo the program shortly
just to see what has happened to your uptake and usage.
What are your messages for people to take home, Angus?
I would say that it's something you need to try.
If you're in a rural area, it really can help your practice.
My father and my brother used it.
My brother loves computers and my father hates them,
and they've both got over the hurdle,
so I'm sure anyone can have a go.
NORMAN: Di? - Just do it.
NORMAN: Sabe?
I have a message for doctors and patients.
For doctors, the main aim of this telehealth model
is to help the patients
so that they don't waste their time on unnecessary travel.
If you keep that in mind, you want to help your patients,
talk to someone and start it tomorrow.
For the patients, when you see someone on screen,
don't look at them like a screen.
Consider that the other person is a specialist
or a doctor or a health professional
who is interested in your care and trying to help you.
Make the connections.
Do you have to change your style of communication as a clinician?
Not really.
Communication skills don't have to change
if you have good communication skills.
Using the camera...
Your communication skills are in a goldfish bowl.
In an ideal situation...
The only thing I had to change was using the camera.
A lot of patients complained I wasn't looking at their eyes.
NORMAN: You were looking at the screen.
Now I look at the camera quite often.
NORMAN: Television 101 here.
The other one I always ask is about, who's out there,
who is on my end, are the doors closed,
but nothing really different.
NORMAN: Carol? - There are many people out there
that could benefit from using telehealth.
In terms of costs, savings, travel time, convenience for consumers,
there are potentially enormous benefits.
A lot of those people are currently missing out.
We need to get the technology out there.
We also need to be informing consumers about the benefits,
making sure they're aware
and helping them to make a decision
about whether or not this technology can help them.
Certainly the indications are
that many consumers would see that as a real benefit
in helping them manage their own health care.
Collecting good information
about what's currently happening with telehealth services
and where we could be going to expand them,
to provide cost-effective, quality services,
there's huge opportunity, we should be doing more of it.
NORMAN: Isabelle? - If you have picture-in-picture,
make sure you put that on
so that you're looking your best in the shot
so that the patient can also look their best
if they're on your side.
Ewen should be wearing a bit of lippy.
He could, but he needs to be in the middle of the shot.
He needs to be a nice shoulders and head.
Take a bit of time getting yourself prepared.
Make sure you have all your patient data.
If you're a photographer, learn to take really good photos
so that they can accompany what you're doing, and just get going.
It can only be of benefit.
I think you did pretty good, Ewen.
EWEN: Thank you. - What's your message?
My message for GPs is that there's plenty of help
to get online and get going with this.
Just do it. It's of tremendous benefit for your practice
and tremendous benefit for your patients.
Have you seen a benefit in recruitment?
I have.
I certainly have seen recruitment of patients
come into the practice because we're doing telehealth.
That's the bottom line, so that's good.
The Rural Health Education Foundation is collating a DVD
which will have on it many of these
resources, as well as a copy
of this panel program.
It will also have a documentary,
Stories From The New Bush Telegraph,
and extended case studies.
This is available on order from the RHEF website.
If you're interested in obtaining more information
about issues raised in this program
or you'd like to watch the program again,
visit the Rural Health Education Foundation's website:
And click on The New Bush Telegraph program web page.
If you're a health professional,
don't forget to complete your CPD assessment form,
which can be completed online.
You'll receive a certificate of attendance
and if eligible, CPD points.
Our thanks to the Australian Government's
Department of Health and Ageing for making the program possible.
Above all, thanks to you for taking the time to watch
and to contribute to our discussion.
We would appreciate your feedback on the program.
Your comments are very important,
and are used to improve our service to you.
Let us know that you watched the program
by sending us an email or text,
and feel free to share any comments.
We'd love to hear your views, good, bad or ugly.
I'm Norman Swan.
Goodbye, and join us again on the Rural Health Channel.
Captions by Captioning & Subtitling International
Funded by the Australian Government Department of Families, Housing,
Community Services and Indigenous Affairs.
As I said, the Rural Health Education Foundation
is producing a DVD with this panel discussion program,
the documentary, Stories From The New Bush Telegraph,
extended footage of case studies
and a number of resources and tools developed
by a wide range of organisations
that support practices to set up and use telehealth.
Order your free copy
by going to the RHEF website: rhef.com.au
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