IT’S 9.30pm. Dr Nicholas O’Ryan is still at his desk, after a long and demanding day at the surgery. But his energy levels are high.
The solo GP, from the tiny NSW town of Canowindra, is fired up with enthusiasm, having entered the new world of video conferencing just a few weeks earlier.
Dr O’Ryan, 55, isn’t overly computer savvy, which partly explains his excitement. He sounds chuffed when he tells Australian Rural Doctor that he set up a video conferencing system in just five minutes. It cost him nothing. He hooked up to Skype and had a spare computer video camera to hand.
Having experienced the buzz of giving his isolated patients quick and easy access to a city psychiatrist, he’s reassured that they’re enthused too. Even a conservative elderly patient with depression and anxiety was impressed by the quality of her first online appointment.
“She told me she felt like the psychiatrist was in the room with her,” Dr O’Ryan says.
While video conferencing has left Dr O’Ryan flying high, it’s a subject that leaves other GPs feeling fatigued and frustrated. Despite the Federal Government launching MBS item numbers and a $6000 incentive in July, it’s clear that the rural GPs who’ve jumped on board are a small, not particularly conservative, minority.
Dr Ewen McPhee, a GP from the remote Queensland town of Emerald, has spent six months trying to get a system operating, with the help of his IT-trained son. He’s keen to get started, but internet speeds are proving a problem.
“Because there are so many fingers in the pie trying to deliver the service and so many providing it, it’s quite a maze to wade through to find the best connections and best speeds,” he says. “Speeds have been an issue for years. My branch practice is really suffering in terms of reliability of service.”
In July Dr Bill Boyd, an obstetrician at Mackay Hospital in Queensland, set up a computer and camera and downloaded Skype. He then contacted all the GPs in the region, including Dr McPhee, to encourage them on board.
“It has scarcely been taken up,” he says.
According to the Health Department, about 1200 rural doctors – including specialists – have claimed the $6000 telehealth incentive. From July to October last year, 899 of the 12 telehealth item numbers GPs can claim had been processed. That’s about 220 per month, nationally.
Those figures are very low, according to Dr Tori Wade. She is working on a PhD that explores the uptake and sustainability of telehealth services in Australia, having spent 15 years as a GP in Adelaide.
“I expected it to be low because every GP I know is booked solid with patients. Why would they spend time trying to work it out, when they’re flat out?”
She says item numbers were introduced too early and is concerned about the long-term implications of rural GPs not being ready to run with them. “There is a danger that two to three years down the track, the government will say ‘That didn’t work’ and cancel them,” Dr Wade says.
Dr Wade’s main concern is shared by every person interviewed for this feature. To put it simply, there is not one system that will communicate with all online specialists. In fact, GPs could potentially need a different system for each specialist they want to consult online.
Dr Wade says there are 50 different types of video conferencing software. While a few claim to be able to interoperate with other software, in reality, they don’t.
“As soon as someone does an update, it falls apart,” she says.
“Running real-time video is like having a canary in your coal mine. If there is any problem the video conference falls over.”
Dr Wade says the compatibility issue is so significant it could lead to telehealth’s undoing.
“I really want it to work and I’m really worried it won’t. I’d like it to take off in the broader scale, but I am not convinced it is going to happen,” she says.
She thinks it is unreasonable to expect busy rural GPs to overcome these hurdles.
“I don’t see why they should. You’ve got them to set up a resource and then you waste their time, asking them to become IT and telecommunications experts.
“I think the Commonwealth Government has got it wrong. If they wanted this to work they really should have supplied a network.”
She says a public switch video network would overcome the problem, just as a public switch telephone network enables Telstra and Optus to shunt calls between their systems.
“Why couldn’t we set something up like that for video calls?” she asks. “Interoperability should be public infrastructure.”
Former GP Dr David Allen agrees that system compatibility is a significant problem and he also doesn’t want it to undermine telehealth’s potential value in rural areas. Having worked in private practice providing occupational health consultations online for many years, he has established Telehealth Solutions Australia, which offers a free system for secure video conferencing.
He says he established the not-for-profit organisation because a lot of doctors were having bad experiences.
“A lot of people are paying far too much money and setting up systems that won’t talk. Ultimately, who loses out? The patient.
“I want doctors to get involved but if it’s too hard they won’t offer telehealth, which means patients will miss out.”
He says his system can manage 1000 simultaneous video consultations.
“We’ve opened it up and given doctors across Australia access to so that they don’t have to pay anything. It’s an easy system to use, providing high definition. It runs off windows and Mac.
“When I tell people this their jaw drops. It’s all paid for. Some of the vendors out there are trying to make a lot of money out of this.”
He says GPs involved in video consultations are “few and far between”. Those who are are largely using Skype and he understands why, although he says it doesn’t give adequate stability or definition. “It’s a nice starting point. It’s a consumer-grade system. GPs are using it and they find it’s easy and accessible.”
Skype isn’t adequate, according to Dr Wade, who became so frustrated with the technical support required by software options that she explored hardware. She became involved in a business specialising in video phones, which she says are more expensive than software, but also more reliable. At this stage, video phones are enabling nurses to call patients at home and supervise them as they take medication, rather than being used broadly in general practice. One GP who has tried them, Dr Tim Kelly from Crystal Brook, SA, wasn’t enthused.
Dr Kelly, who works at a three-partner general practice, found the extra equipment cumbersome compared with using Skype.
For the past four years he has used Skype to connect patients in his region to a rheumatologist in Adelaide. Two interns run the program, which ran initially as a grant-funded pilot.
“One [intern] sees the patient for 15 minutes, and then they sit in for the 15-minute consultation with the rheumatologist, while the other intern is doing the next consult in the next room.”
Dr Kelly says its good training for interns to be dealing with specialists directly, and he’s looking to expand the model to include the practice’s visiting endocrinologist.
Dr Kelly says while he’d like to upgrade to something more secure than Skype, he doesn’t consider Skype a large risk in the context of rheumatology.
Skype’s safety also doesn’t particularly concern Dr Trevor Lord, a GP who works for the Kimberley Aboriginal Medical Services Council in WA. Dr Lord is one of the country’s more technologically savvy GPs. He is one of the Clinical Leaders on the National E-Health Transition Authority, and recently established an electronic patient record system for 21,000 patients in the Kimberley.
He says Skype isn’t the best tool, but it works, it’s easy and security issues are largely overplayed. “It may be that the Russians have broken into Skype and are watching our consults and we don’t know, but it’s unlikely,” he says.
However, the Kimberley “must have the worst bandwidth in Australia”. “I deal in Broome in bits per second, not mega bits per second,” he says.
Dr Lord doesn’t have the upload speeds required for any kind of video conferencing. Instead, he takes a photo – say of a rash or infection – and sends it to a specialist using his mobile phone. They then call and discuss it, which he says works well. Other forms of this “store and forward” approach, sometimes using video footage or images which are sent over the internet, have been used to get input from ENT specialists and ophthalmologists.
He says being able to conduct six-week post-surgical checks using video conferencing would make an enormous difference to Aboriginal people who are reluctant to travel the significant distances to Perth for a five-minute consultation. He estimates they would save the health system $2000-$3000 for each visit.
But he says once you leave regional centres in WA, internet access is “all over”.
He says national broadband went into Geraldton and Mandurah – “they consider that to be rural”.
“We’re going to have to sit around until 4G gets going,” he says.
Having said that, he said WA does have its own unique challenges when it comes to establishing IT infrastructure. Dr Lord says last year a cable that carried a 3G system from Derby to Broome was cut.
“We lost communication for two or three days,” he says. “Allegedly, a crocodile chewed it.”
LIKE TAKING THE PATIENT TO THE SPECIALIST YOURSELF
Dr Nicholas O’Ryan had a serious incentive underpinning his foray into telehealth, and it was nothing to do with a $6000 Federal Government grant. The isolated rural GP was concerned about a family member with depression and wanted him seen by a good psychiatrist, fast.
“I looked locally and they couldn’t see him in Bathurst or Orange. I needed something immediate,” says Dr O’Ryan, who has practised in Canowindra, in central-west NSW, for 25 years.
He spoke with Sydney psychiatrist Dr Errol Jacobson, who works as a visiting medical officer for Dr O’Ryan’s local division, where he’d been involved in a tele-psychiatry trial.
Dr Jacobson encouraged Dr O’Ryan to set up a Skype account, so that the consultation could take place online between Canowindra and Sydney. “I thought it sounded logical. I thought, oh well, let’s try it,” Dr O’Ryan says.
He set up a computer in his nurse’s room, and dug out a few $70 video cameras he’d bought to improve practice security.
“I set up a dedicated Skype account. It took five minutes, if that, and it works amazingly well.”
When Dr O’Ryan spoke to Australian Rural Doctor, five of his patients had seen Dr Jacobson, via video, from the comfort of Dr O’Ryan’s surgery. And Dr O’Ryan had seen a range of advantages he hadn’t anticipated, largely because the process overcomes the delays and limitations of referral and follow-up letters.
Dr O’Ryan sits with his patient and introduces them to Dr Jacobson. Dr O’Ryan leaves the room while the consultation takes place, but returns once the patient has left. He then discusses Dr Jacobson’s management plan in depth.
“Where else could you get that?” says Dr O’Ryan.
“It’s like taking your patient to the specialist. You get better feedback and you can ask appropriate questions. It’s much better care and it is more satisfying. You can develop a relationship.”
Dr Jacobson says there is great benefit in being able to discuss a management plan so it can be put in place instantly.
“Rural medicine has to be a collaboration between GP and specialist,” he says. “A lot of management is carried out by the GP, so it cuts through the whole waiting game.
“Face-to-face is definitely better. But if face-to-face is 100%, then telemedicine is 98%. It’s made up with accessibility, cost and assists the GP.”
About one-fifth of Dr Jacobson’s consultations are now held via video conference, and that proportion is growing. He recently conducted 12 consultations from home, on his laptop, travelling the equivalent of 5000km without leaving his desk. At his practice, in Bronte, Sydney, he will see a patient face-to-face, then one in Tasmania, another in his rooms, and then another in Parkes.
Having conducted more than 100 video consultations, he’s never had a complaint or concern about quality. “I always have my iPad nearby and a landline phone as a backup as well. [But being online has] never impeded my ability to establish a diagnosis, establish a management plan or develop a report with someone.”
Dr Jacobson finds it odd that some GPs have found video conferencing a challenge to establish. “Perhaps they’re losing the simplicity of it. It’s frighteningly easy to set up. All GPs need is Skype, or an equivalent AV software program, a web cam and microphone through a computer in a room. That’s it.”
NO ONE-SIZE-FITS-ALL SOLUTION
About 200 doctors have contacted ACRRM’s Telehealth Advisory Service for help with setting up video conferencing. Vicki Sheedy, ACCRM’s Strategic Programs Manager, e-Health, says solutions depend on what bandwidth GPs have and everyone’s context is different.
ACCRM’s online system provides tailored solutions, based on individual circumstances and needs. “They describe their technical environment and the specialists they need to talk to. We give them a range of options for them to consider.”
ACRRM also has a free directory that lists telehealth-enabled clinicians by specialty. It indicates what technology they use and where they are located. The ACRRM address is http://www.ehealth.accrm.org.au/
VIDEO A NATURAL FIT FOR RURAL GPs
As Chief Medical Officer for the Australian Antarctic Division, Dr Jeff Ayton (above) has had the opportunity to trial telemedicine technology that has supported health care in other isolated environments.
He’s worked with NASA, through a research memorandum of understanding, but says there’s an emphasis on ‘store and forward’ technology – SMS and email – rather than real-time video.
He says the distances involved in space travel result in a delay of up to 20 minutes in messages getting through.
Video conferencing also hasn’t played a significant role in Antarctica, despite phone-based telemedicine having been practised in support of Australian expeditions since 1948.
While there is the capacity for video conferencing, there hasn’t been the clinical need to use it, and there are significant challenges in ensuring the patient and doctors are available at the same time.
Those issues aside, Dr Ayton applauds the Federal Government’s significant investment in video conferencing, which he says will expand the number of specialists becoming involved.
“It’s a fantastic initiative which cuts across the inequities of specialist access in remote and rural Australia,” says Dr Ayton, who is chair of ACRRM’s National Telehealth Advisory Committee. Dr Ayton says rural GPs should now be considering video conferencing for all referrals, when they think it clinically appropriate.
He says that one of the barriers to uptake is that one system cannot connect to every doctor. But GPs should start by working with specialists they already refer to, and look at having a number of different systems in place.
“Until the technology is ubiquitous and there is connectivity between the various video conferencing systems, there is going to be a challenge,” he says.
“There are ways to get a fit-for-purpose solution but it will take years to get a more ubiquitous solution.”
He says using Skype may not be suitable for sensitive health discussions where there may be significant concerns about privacy.
“It needs to be a judgement of the clinicians at both ends,” he says. “It would be very concerning if video feeds of a medical nature reached the public domain.”
However, one way of managing the risk was to use Skype for video and the telephone for voice, he said.