2021 Predictions Series – Part 3 Making telehealth sustainable

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Indigenous Health Screening assessment

The arrival of COVID-19 ignited an explosion in telehealth. Now the goal is harnessing that energy to make telehealth services sustainable, says the Director of The University of Queensland’s Centre for Online Health (COH), Professor Anthony Smith.

With more than 20 years’ experience in research, involving the planning, implementation, and evaluation of new telehealth solutions for clinicians and patients, Professor Smith has seen telehealth evolve from outlier technology, to its recent role as a crucial tool for remote – and safe – healthcare during the pandemic.

Professor Anthony Smith telehealth services expert

What Professor Smith expects will evolve is a mature model where telehealth is an integral component of everyday health services.

“Prior to COVID-19, not many people really understood telehealth: It wasn’t being offered all the time in general practice; it was offered occasionally in a hospital setting or in Aboriginal medical centres; and rarely offered in nursing homes,” said Professor Smith, who also chairs the annual International Successes and Failures in Telehealth Conference in Australia.

“But suddenly, everyone is doing it out of necessity and people are becoming much more accustomed to it and realising the benefits; so, I think it’s important to think about telehealth’s future, long term, and what is needed to sustain it.”

Prof Anthony Smith visiting remote islands
Torres Strait Islands travel: In transit – Prof Anthony Smith visiting remote islands through the Torres Strait, via daily charter flight service. Engagement with each community is the first priority with any project involving Aboriginal and Torres Strait Islander communities.

Even conservative health sectors have embraced telehealth: “We saw examples where senior consultants – who, before COVID-19 had shown limited interest in using telehealth – were suddenly calling us on the phone saying, ‘we need to start telehealth immediately; can you come and help us?’ So, in a way, it’s forced them into doing it!”

Professor Smith, who is also Adjunct Professor of Digital Health and Telehealth at the University of Southern Denmark, has nominated three key requirements for telehealth’s sustainability:

1. Funding and remuneration

How exactly do you put a price on telehealth services?

According to Professor Smith, the Australian Government took a step in the right direction when it expanded Medicare funding opportunities for telehealth services in early 2020, essentially including telephone consultations and removing the geographical boundaries that originally existed. More recently, the government announced that some of these Medicare items will remain permanent.

However, more needs to be done: “One of the myths around telehealth to date is that it is done to save money and that’s not essentially true,” said Professor Smith.

“Telehealth is about providing better quality care to more people and we have to change our way of thinking and accept the fact that telehealth may actually cost a little bit more.”

“If we are genuinely committed to providing good quality services to more people, that is going to come at a price. That is one of the key messages and I believe our government leaders are beginning to realise and appreciate the importance of telehealth. The recent support demonstrated through Medicare funding opportunities is a good example of government support on a national scale.”

Paying for telehealth services

Professor Smith is no stranger to advising government on this issue: in 2010 he was a lead investigator on a report on funding video-conferencing consultations through the Medicare Benefits Schedule. The government introduced legislation in 2011 based on his report findings.

During 2020, says Professor Smith, the health sector showed signs of moving away from a “fee-for-service” approach, to a more indirect model that goes beyond telephone and video conferencing to also include remote medical monitoring: This facilitates the collection of patient health data for sharing with GPs, specialists, and allied health professionals, and further upends the current funding and remuneration models.

“If patients don’t need to come in and see their specialist and if instead, information can be shared with a specialist and monitored and responded to only when required, that’s very difficult to put a dollar value on,” said Professor Smith.

If a health professional is sitting with a patient; if a GP is involved in a tele-consult; or a specialist is preparing a case and talking remotely with a GP or a patient, all the clinicians involved in the interaction need to be paid for their service.

“Services need to be clearly defined and we need to decide how they’re going to be remunerated,” said Professor Smith.

“There has to be a change in our thinking. Do we adopt a funding model where health services are bundled into packages where a dollar value is given to a health service (or to a patient) for a multidisciplinary service?  In this case, the health service would ultimately choose the most appropriate service delivery methods to meet a desired clinical outcome within the budget. Then you’ve got to establish a benchmark or a set of performance or quality measures that can be used to judge performance and quality of care.”

2. Developing a skilled workforce

One major obstacle to overcome will be improving telehealth skills and training, says Professor Smith.

“Whether you’re talking medical, nursing or allied health, people are trained to work and provide services in a certain way, and telehealth – or digital health more broadly – implies a different way of working; it’s a different way of interacting with our patients that requires different communication skills and techniques; it requires different physical [health] assessment techniques,” he said.

Professor Smith estimates that around 93 percent of telehealth activity is currently via telephone consults rather than video; “so, we need to continue working with clinicians and health services to change this figure. Video conferencing for example offers the advantage of seeing the patient and being able to collect information not easily detected over the phone.”

Training the trainers

Developing and implementing systematic and regular training and education – whether in the workplace or university – will take time.

Professor Smith explained that The University of Queensland’s (UQ) Faculty of Medicine and School of Health and Rehabilitation Sciences have combined their expertise to create a telehealth curriculum. The curriculum will be used as a micro-credential online course, and in pre-registration courses in medicine, nursing, and allied health.

The content is generic, with discipline-specific modules to target groups such as doctors, nurses, speech therapists, occupational therapists, physiotherapists, and pharmacists. It includes a variety of topics such as using technology, communication skills, telehealth planning, and service development.

“You need a modified skill set to be able to communicate via telehealth,” explains Professor Smith.

“How do you manage eye contact? How do you manage emotional conversations? How do you determine risk? How do you manage a consult where you can’t put your hands on a patient, but you’re relying on someone at the other end to help you with that assessment? All of these skills are important.”

Promoting primary health

According to Professor Smith, the explosion in telehealth has seen a focus on the primary carer – the GP, the practice nurse, or the allied health professional – and innovative telehealth training will see this trend increase.

COH is launching a telementoring program in Queensland called Dementia Echo, which is funded by the Australian Department of Health: Indigenous Australians’ Health Programme Emerging Priorities grant scheme. The project is in partnership with the Queensland Aboriginal and Islander Health Council (QAIHC) and Metro South Health. The program simultaneously combines improved access to specialist healthcare for Indigenous Australians living with dementia, with education for GPs, nurses, and allied staff across Aboriginal Community Controlled Health Organisations (ACCHO).

The program will be led by a panel of dementia experts including a geriatrician, a nurse, and an allied health professional. A monthly video conference will allow the panel to present information and training to ACCHO staff, who in turn can present patient cases for feedback and advice from the expert panel.

“The long-term effect will be that the primary care providers will be able to provide specialist care to their patients without having to travel, and we’re also training up these GPs and they’re going to develop skills through the very process of tele-mentoring,” said Professor Smith.

“Our focus is on empowering health-service staff in these communities through training and support.

“The skills and experience gained then remain in the community, where local staff can deliver their own education programs, conduct dementia assessments, and prepare cases for telehealth consultation.”

Ironically, says Professor Smith, the remote nature of telehealth technology will in fact help remove the divide between quaternary, tertiary, and primary carers.

“Dementia ECHO should bring health service providers closer together.”

3. Improving digital ecosystems and integrating telehealth services into routine care.

This year, says Professor Smith:

  • There needs to be a focus on reclassifying telehealth as a routine healthcare fixture, rather than a temporary arrangement.
  • Health providers need to understand telehealth limitations, including the important point that telehealth should be delivered in conjunction with face-to-face appointments – not as a replacement.
  • Health providers need to carefully assess their clinical environment, as well as the health needs and location of their patients, so they can choose the most appropriate telehealth application and system for their practice.
  • Practices need to take the time to create written telehealth policies, procedures, and guidelines, covering everything from telehealth patient referrals, to patient telehealth consultations, and the provision of telehealth patient treatments.

Finding the most effective telehealth solution

In 2012, Professor Smith and COH began working with Metro South Health (MSH) in Brisbane on processes related to the implementation, delivery, and evaluation of MSH telehealth services.

Based primarily at Princess Alexandra Hospital, in the first year of operation, MSH reported around 400 telehealth appointments; in 2019, this number grew to 6,000; and in 2020, COVID-19 saw the annual number of telehealth appointments surge to almost 30,000. All these appointments were done by video conference.

During these nine years, telehealth services at MSH also expanded to more than 110 clinical specialities, including endocrinology, dermatology, immunology, hepatology, infectious disease, cancer therapy, diabetes, orthopaedics, rheumatology, and geriatrics.

Before rolling out each individual telehealth service, the COH team engaged with clinicians to ensure their telehealth system and infrastructure was the most appropriate for clinicians and patients. This approach, says Professor Smith, should be adopted by any practice using telehealth.

“We help the clinical teams understand where their priorities might be; which patients they are targeting; and what is the most appropriate telehealth application for their patients depending on condition and location,” said Professor Smith.

“We help facilitate, we do the training and the support. Technically, we make sure that we remove any obstacles and that all systems are in place.

“Eventually these services become independent and run themselves with very limited support over time.”

Some other integrated telehealth systems Professor Smith has researched and established include:

  • Post-acute burns care and telemedicine at the former Royal Children’s Hospital in Brisbane. After extensive engagement with the multi-disciplinary burns team, this telehealth model saw regional occupational therapists and nurses trained to deliver outpatient care with the support of specialists via video conference. In the first ten years of the program, there were more than 3,500 telehealth burns consultations, accounting for around 14 percent of all outpatient appointments in the burns unit.
  • Telehealth services for Indigenous children. More than 12 years ago, Professor Smith was instrumental in the creation of a mobile health clinic in the south-east Queensland town of Cherbourg. The van services thousands of Indigenous children providing timely and convenient screening for chronic ear conditions. The clinical information collected by Aboriginal health workers is uploaded to an online database, which is accessible to specialists in Brisbane who routinely review cases and provide clinical management advice. The proportion of children being screened for chronic ear conditions has increased from around 38 percent to 85 percent of all eligible cases in the community.
Indigenous dance performance in front of mobile health clinic
Cherbourg community celebration which marked the commencement of the mobile “telehealth” ear screening service in Cherbourg.

The challenge of internet connectivity

Professor Smith also believes the industry needs to collaborate to ensure a digital divide does not grow between those who can and cannot access telehealth services.

Australia’s National Broadband Network (NBN) is continuing to roll out across the country, but connectivity can still be problematic in some rural, remote, and urban areas.

“My hope is, in the next five years or so, many of those issues will be resolved and people will be able to access affordable internet,” said Professor Smith.

“There are certainly options like satellite connections, but access and affordability are important factors, and we don’t want to discriminate and limit peoples’ access. We have to ensure we’re really looking at this through the eyes of everybody and not just a proportion of our population.”

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Further information: Centre for Online Health, The University of Queensland

Research Profile and contact information: Professor Anthony Smith