An analysis of why telehealth systems in Australia have not always succeeded

Telehealth programmes are rather similar to humans in the way that they are planned, develop, grow and ultimately die or disappear. To achieve good life expectancy for a telehealth programme there appear to be three major needs: nurturing, which includes the provision of money, ideas, education, training and innovation; experience, which involves an integrated management process, the achievement of long and wide patterns of usage, the development of updated policies and procedures and the involvement of multiple disciplines; success, which involves evidence of outcomes, evaluation and research, and, most important, the sharing of information through scientific and popular press publications, and conferences and collaborations with internal and external groups. The future of telehealth in Australia is at a watershed. There are now a substantial number of programmes, and there has been a large amount of financial and human investment in telehealth around the nation. There is, however, no forum for national leadership, no national association and little support at federal government level.

Mental health telemedicine programmes in Australia

A national survey of mental health telemedicine programmes was conducted and data collected on their catchment areas, organizational structure, equipment, clinical and non-clinical activity, and use by populations who traditionally have been poorly served by mental health services in Australia. Of 25 programmes surveyed, information was obtained for 23. Sixteen programmes had dealt with a total of 526 clients during the preceding three months. Of these, 397 (75%) were resident in rural or remote locations at the time of consultation. Thirty-seven (7%) were Aboriginals or Torres Strait Islanders. Only 19 (4%) were migrants from non-English-speaking backgrounds. The programmes provided both direct clinical and secondary support services. Overall, the number of videoconferencing sessions devoted to clinical activity was low, the average being 123 sessions of direct clinical care per programme per year. Videoconferencing was also used for professional education, peer support., professional supervision, administration and linking families. The results of the study suggest that telehealth can increase access to mental health services for people in rural and remote areas, particularly those who have hitherto been poorly served by mental health services in Australia.

Taking telehealth to the bush: lessons from north Queensland

Networking North Queensland (NNQ) was a two-year project to improve access to health services in rural and remote communities. The project involved email and Internet access in 61 communities, in a region almost three times the size of the UK. Videoconferencing equipment was also installed at 21 sites and a total of 197 h of videoconferencing was recorded at 10 of the remote sites over 12 months. As a result of the project, health consumers enjoyed improved access to medical, specialist, allied health and primary health services. In addition, health service providers had better access to reliable, up-to-date health-care information via intranet and Internet services. Consideration of local issues-local needs and existing resources-was vital to the achievements of the project. Community involvement and community access were also important factors in its success.

Videoconferencing in the Queensland health service

Videoconferencing was introduced in the Queensland health service in 1995. By the end of 1999, there were more than 150 videoconferencing units in health facilities around the state. Six audits of videoconferencing usage were conducted using similar methodology at six-month intervals from November 1997 to May 2000. Between November 1997 and November 1999, the number of calls more than doubled, from 566 to 1378. Hours of usage almost trebled, from 671 to 1724. The average duration of calls remained similar, at about I h 12 min. The proportion of calls involving more than two sites (multipoint videoconferences) increased from 44% to 65%. The majority of the activity was for education (including training). Videoconferencing was also used for administration and clinical care. Mental health staff were the heaviest users, but use by health professionals from other specialty areas increased during the study period. The Queensland health service has realized a number of important benefits from telehealth.

Telehealth and the diagnosis and management of cardiac disease

The financial and personal burden of chronic cardiac disease is high. Costs are likely to increase over the next few decades. Promising applications of telehealth have appeared in the diagnosis and management of cardiac disease and there are indications that telehealth services can improve the management of chronic cardiac disease as well as extend services to remote and rural populations. Telehealth has been applied to the capture of symptoms of cardiac disease with electrocardiography and echocardiography, to the management and rehabilitation of recently discharged patients, and in peer-to-peer consultation where remote expertise can facilitate diagnosis. Telehealth promises cost reductions in service delivery, although there is a need for properly controlled cost-effectiveness trials to underpin telehealth with a firm evidence base.

Minimum acceptable standards for digital compression of a fetal ultrasound video-clip

If the Internet could be used as a method of transmitting ultrasound images taken in the field quickly and effectively, it would bring tertiary consultation to even extremely remote centres. The aim of the study was to evaluate the maximum degree of compression of fetal ultrasound video-recordings that would not compromise signal quality. A digital fetal ultrasound videorecording of 90 s was produced, resulting in a file size of 512 MByte. The file was compressed to 2, 5 and 10 MByte. The recordings were viewed by a panel of four experienced observers who were blinded to the compression ratio used. Using a simple seven-point scoring system, the observers rated the quality of the clip on 17 items. The maximum compression ratio that was considered clinically acceptable was found to be 1:50-1:100. This produced final file sizes of 5-10 MByte, corresponding to a screen size of 320 x 240 pixels, running at 15 frames/s. This study expands the possibilities for providing tertiary perinatal services to the wider community.

Realtime fetal ultrasound by telemedicine in Queensland. A successful venture?

We have established a realtime fetal tele-ultrasound consultation service in Queensland, which has been integrated into our routine clinical practice, The service, which uses ISDN transmission at 384 kbit/s, allows patients in Townsville to be examined by subspecialists in Brisbane, 1500 km away. For the 90 tele-ultrasound consultations performed for the first 71 patients, 90% of the babies have been delivered, and outcome data have been received on all the pregnancies. All significant anomalies and diagnoses have been confirmed. The referring clinicians would have physically referred 24 of the 71 patients to Brisbane in the absence of telemedicine. A crude cost-benefit calculation suggests that the tele-ultrasound service resulted in a net saving of A$6340, and at the same time enabled almost four times the number of consultations to be carried out.

Research into telehealth applications in speech-language pathology

A literature review was conducted to investigate the extent to which telehealth has been researched within the domain of speech-language pathology and the outcomes of this research. A total of 13 studies were identified. Three early studies demonstrated that telehealth was feasible, although there was no discussion of the cost-effectiveness of this process in terms of patient outcomes. The majority of the subsequent studies indicated positive or encouraging outcomes resulting from telehealth. However, there were a number of shortcomings in the research, including a lack of cost-benefit information, failure to evaluate the technology itself, an absence of studies of the educational and informational aspects of telehealth in relation to speech-language pathology, and the use of telehealth in a limited range of communication disorders. Future research into the application of telehealth to speech-language pathology services must adopt a scientific approach, and have a well defined development and evaluation framework that addresses the effectiveness of the technique, patient outcomes and satisfaction, and the cost-benefit relationship.

Barriers to effective cancer pain management: A survey of hospitalized cancer patients in Australia

The purpose of this study was to examine attitudinal barriers to effective pain management in a consecutively recruited cohort of 114 cancer patients from four Australian hospitals. When surveyed, 48% of this sample reported experiencing pain within the previous 24 hours. Of these, 56% reported this pain to be distressing, horrible or excruciating, with large proportions indicating that this pain had affected their movement, sleep and emotional well-being. Three factors were identified as potentially impacting on patients responses to pain-poor levels of patient knowledge about pain, low perceived control over pain, and a deficit in communication about pain. A trend for older patients to experience more severe pain was also identified. These older patients reported being more willing to tolerate pain and perceive less control over their pain. Suggestions are made for developing patient education programs and farther research using concepts drawn from broader social and behavioral models. J Pain Symptom Manage 2002:23:393-405. (C) U.S. Cancer Pain Relief Committee, 2002.

Physical outcome measurements via the Internet: reliability at two Internet speeds

We have developed a software application to enable interactive rehabilitation via the Internet. The reliability of the telemedicine application was examined by comparing it with face-to-face assessment. The physical outcome measures assessed were knee range of motion, quadriceps muscle strength, limb girth and an assessment of gait. One therapist performed both in-person and Internet-based measurements of all outcome measures on 20 normal subjects. There was good agreement between the two techniques (the 95% limits of agreement included zero for all the variables studied). Internet assessments were conducted at two bandwidths: ISDN at 128 kbit/s and the telephone network at 17 kbit/s. Bandwidth had no significant influence on any of the measures. This study suggests that Internet-based physiotherapy interventions delivered to the home are suitable for further development.

Assessing clinical reasoning: a method to monitor its development in a PBL curriculum

The aim of this study was to develop and trial a method to monitor the evolution of clinical reasoning in a PBL curriculum that is suitable for use in a large medical school. Termed Clinical Reasoning Problems (CRPs), it is based on the notion that clinical reasoning is dependent on the identification and correct interpretation of certain critical clinical features. Each problem consists of a clinical scenario comprising presentation, history and physical examination. Based on this information, subjects are asked to nominate the two most likely diagnoses and to list the clinical features that they considered in formulating their diagnoses, indicating whether these features supported or opposed the nominated diagnoses. Students at different levels of medical training completed a set of 10 CRPs as well as the Diagnostic Thinking Inventory, a self-reporting questionnaire designed to assess reasoning style. Responses were scored against those of a reference group of general practitioners. Results indicate that the CRPs are an easily administered, reliable and valid assessment of clinical reasoning, able to successfully monitor its development throughout medical training. Consequently, they can be employed to assess clinical reasoning skill in individual students and to evaluate the success of undergraduate medical schools in providing effective tuition in clinical reasoning.

Telemedicine for new neurological outpatients: putting a randomized controlled trial in the context of everyday practice

In a retrospective review, the telemedical management of 65 outpatients from a randomized controlled trial (RCT) of telemedicine for non-urgent referrals to a consultant neurologist was compared with the management of 76 patients seen face to face in the same trial, with that of 150 outpatients seen in the neurology clinics of district general hospitals and with that of 102 neurological outpatients seen by general physicians. Outcome measures were the numbers of investigations and of patient reviews. The telemedicine group did not differ significantly from the 150 patients seen face to face by neurologists in hospital clinics in terms of either the number of investigations or the number of reviews they received. Patients from the RCT seen face to face had significantly fewer investigations but a similar number of reviews to the other 150 patients seen face to face by neurologists (the disparity in the number of investigations may explain the negative result for telemedicine in that RCT). Patients with neurological symptoms assessed by general physicians had significantly more investigations and were reviewed significantly more often than all the other groups. Patients from the RCT seen by telemedicine were not managed significantly differently from those seen face to face by neurologists in hospital clinics but had significantly fewer investigations and follow-ups than those patients managed by general physicians. The results suggest that management of new neurological outpatients by neurologists using telemedicine is similar to that by neurologists using a face-to-face consultation, and is more efficient than management by general physicians.

A review of guidelines and standards for telemedicine

We conducted a review to establish the range and scope of current telemedicine guidelines and standards. Published guidelines were identified by searching the Medline and Telemedicine Information Exchange (TIE) databases, and by performing a Google search using the term 'telemedicine guidelines'. Three types of guidelines were identified, namely clinical, operational and technical. Clinical guidelines included those for teleradiology, telepsychiatry, home telenursing, minor injuries telemedicine, surgical telemedicine, teledermatology and telepathology. Operational guidelines included those for email communication, Internet access and videoconferencing. Technical guidelines included those from the American Telemedicine Association and the US Office for the Advancement of Telehealth. The main standards relevant to telemedicine include those of the International Telecommunication Union and the DICOM standard. The scarcity of guidelines and standards suggests that telemedicine is not yet near to routine use. If an international telemedicine organization were to take responsibility for defining guidelines, under the direction of clinicians with appropriate telemedicine experience, this might speed up their development.