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A report prepared for NOIE in September 1999 on trends and policy issues in the evolution of electronic service delivery in the health sector in Australia

Chapters: Foreword - Rationale - Key Terms - Policy Framework - Workshops Findings - International - Further Australian Case Studies  - Strategic Directions - Bibliography - Acknowledgements

Prepared by John Mitchell of John Mitchell & Associates for the Federal Australian Department of Communications, Information Technology and the Arts (DOCITA)

John Mitchell & Associates
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©Commonwealth of Australia 1999

Published by the Commonwealth Department of Communications, Information Technology and the Arts (DOCITA) to provide information on electronic commerce initiatives.  DOCITA does not assume responsibility for the  content or opinions expressed by the author in this report and disclaims any liability for errors or omissions.

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MINISTERIAL FOREWORD

The increasing use of information and telecommunications technologies, including Internet technologies, has emerged as a key tool to drive efficiency and effectiveness in Australia's health system.

Health, in common with other sectors of the Australian economy, is increasingly adopting information and telecommunications technologies and electronic commerce strategies to deliver services to consumers and customers. Australian innovations in the application of information and telecommunications technologies in the health sector are amongst the best in the world.

In 1998 the Government released its report Fragmentation to Integration: the Telemedicine Industry in Australia. Extensive consultations including five national workshops were held to discuss the key themes. This led to the preparation of this new report which discusses the relationship between and transition from Telemedicine to Electronic Health - From Telehealth to E-Health: The Unstoppable Rise of E-Health.

Electronic Health (e-health) is much broader than telemedicine or telehealth. It covers the use of digital data transmitted electronically - for clinical, educational and administrative applications - both locally and at a distance. Hence, e-health is the overall field that encompasses telemedicine.

This report profiles Australia's success in positioning itself as part of the e-health age. The case studies chosen for this report illustrate that Australians are  developing and adopting new technologies as impressively as the rest of the world. Australian researchers working with clinicians have developed unique e-health technologies and applications that deliver improved healthcare. The case studies are chosen from a cross-section of e-health fields, and represent examples from every State and Territory in Australia.  A range of international case studies has also been included to illustrate the extent and types of applications occurring globally.

The rise of e-health is inevitable, and will create improvements in the delivery of health services for health providers, consumers and funding bodies. This report makes a valuable contribution by outlining the need to overcome barriers to widespread adoption of new technologies. The report also highlights emerging trends in the information economy and their relevance to the delivery of better, more cost effective, health service delivery in Australia. We trust you will find it useful, as we enter the new era of e-health.

Richard Alston
Minister for Communications,
Information Technology and the Arts

Dr Michael Wooldridge
Minister for Health and Aged Care

EXECUTIVE SUMMARY

This report on e-health was commissioned by the National Office for the Information Economy and prepared from April-July 1999 by John Mitchell, from John Mitchell & Associates.

Brief

In July 1998 the Commonwealth Government launched Fragmentation to Integration: the Telemedicine Industry in Australia (Mitchell, 1998). The report advocated that telemedicine or telehealth should be absorbed into the mainstream of health. Following extensive consultations and five national workshops to discuss the report in 1998-99, it became apparent that it was increasingly difficult to argue that telemedicine or telehealth, in the sense of using "tele" technologies to deliver health services, was entirely discrete from the use of information technologies in the health arena.

Hence the decision was taken to prepare this report to describe new and emerging practices in the health industry that use combinations of information and telecommunication technologies (IT&T). The research indicated that telemedicine or telehealth is now becoming part of a broader and fast growing development that can be called electronic health or, in brief, e-health.

Definitions

Preston (1993) defined telemedicine as "a system of health care delivery in which physicians examine distant patients through the use of telecommunications technology", emphasising the role of doctors. Health Online (1997) defined telehealth as 'healthcare at a distance', emphasising that all health professionals, from nurses to specialists, could use telecommunications for healthcare.

The period 1998-1999 has seen a significant rise in interest in the field of e-commerce, with the focus on business-to-business electronic communication. E-health is taken to be a subset of e-commerce. E-health is a new term needed to describe the combined use of electronic communication and information technology in the health sector.

However e-health is not simply about business transactions. This report shows that health industry practitioners are now using IT&T for a variety of purposes besides business or administrative transactions. The case studies in this report demonstrate that e-health is the use in the health sector of digital data - transmitted, stored and retrieved electronically - for clinical, educational and administrative purposes, both at the local site and at a distance. Hence e-health is the overall field that encompasses telemedicine and telehealth.

Diagram 1: Relationship of e-commerce, e-health and telemedicine

Methodology

The major sources of information for this report are the presentations and discussions at the five national workshops held from November 1998 - May 1999 to discuss the findings of the report Fragmentation to Integration: the Telemedicine Industry in Australia (Mitchell, 1998); a collection of a range of Australian and overseas e-health case studies; Internet sites; and a review of current literature.

Major themes and findings

The study argues that the effectiveness of telehealth is currently limited by positioning telehealth outside the mainstream of healthcare. Some critics perceive telehealth to be a peripheral activity and a novelty area for technological enthusiasts. The major cost benefits of telehealth will not be realised unless this perception that it is an 'add on' and an experiment is changed. Telehealth is more likely to be sustained if it is seen as part of a larger domain, e-health.

Convergence of Information Technology and Telecommunications

In contrast to the difficulty many telehealth projects have in becoming part of mainstream health service delivery, there are strong business cases emerging in many areas of e-health, such as the use of call centres and online health information services. These business cases indicate that e-health services are driven by business principles and are fast becoming part of mainstream health care delivery.

The study indicates that with the relentless convergence of technologies and with the consequent increase in ability to perform multiple functions with those technologies, it is unwise to solely emphasise the distance factor, the "tele", in telehealth. The combination of information technologies and telecommunications (IT&T), of information technologies and telehealth, is beginning to have a significant effect on healthcare.

Drivers

There are a number of drivers of e-health, including increased efficiencies from improvements in business and clinical practices and processes, and demand from consumers for improved access to quality health care information and services. Healthcare lends itself to the strategic application of online technologies because of its size, the current inefficiencies of paper-based records, the intense need for up-to-date information to provide quality healthcare and because interest is growing among consumers in Australia and overseas in using the Internet to access a range of information and services.

Consumer and provider interest in health information, evidence-based information and the potential applications of IT&T, are driving much of the move to e-health. Various USA surveys have indicated that the proportion of USA adults that have used the Internet for health information may be as high as 40-60 per cent of adult online users, and the trend is increasing. There is a need to coin new phrases such as "customer-based medicine" or "online healthcare", to reflect the new business models being developed as a result of the availability of ubiquitous Internet technology and an ever expanding range of online services.

A trend in the USA is for large IT companies such as Intel and Microsoft to merge with health online companies, to form new companies exploiting the capabilities of online communication. The types of companies in the USA that are providing e-health services can be separated into three broad, but not entirely distinct, categories: those providing content and related services, those providing business-to-business or business-to-consumer services and those providing networks or software for e-health. The categories overlap and will do so more in the future, with the convergence of technologies, but temporarily distinguishing between them now may help to highlight some of the components of the e-health industry.

Australian case studies

A series of reports issued by the Commonwealth Government over the last three years demonstrate a consistent focus on identifying the triggers that will enable Australia to benefit from the information economy. Health is viewed as one of the key sectors that should benefit from the information economy.

Some e-health activities profiled in this report that are products of the information economy and use both IT&T include Victorian nurses making house calls in rural areas equipped with hand held computers that can be connected via a mobile phone to databases at headquarters; highly qualified cardiology nursing staff answering telephone calls from around Australia in the call centre of the National Heart Foundation; radiologists using a combination of teleradiology and live videoconferencing to link from Adelaide to Alice Springs; and general practitioners (GPs) accessing powerful new pharmacy databases and producing electronic scripts. In practice in the health sector, IT&T are being blended with telehealth, becoming part of a larger field, e-health.

A range of case studies of Australian e-health activities in this report illustrates that Australian ingenuity in the bundling and application of technologies is as impressive as the examples from the rest of the world. Australian researchers working with clinicians have developed some unique e-health technologies and applications. The Australian case studies are not meant to be an exhaustive list of all the e-health activities in Australia. They are a deliberately chosen cross-section from a range of fields, including telehealth to the home, community e-health, health call centres, teleradiology, telecardiology, tele-mental health, GP networks, Internet health networks and electronic pharmacy ordering. At least one example is included in this report from each State and Territory.

Generally, the Australian case studies in this report involve the use of both telecommunication technologies such as videoconferencing, telephone or the Internet together with information technologies such as computer databases and other image capture, electronic ordering, storage and retrieval systems. Besides this use of combinations of information and telecommunications technologies, the use of the Internet is starting to expand the boundaries of e-health. Internet case studies in this report record such Internet-based activities as GP communication with hospitals and pharmacists via the Internet; provision of professional development for remote health professionals using videoconferencing and the Internet; and patients communicating with health professionals via the Internet.

Overcoming barriers

There are some regulatory and behavioural barriers to the successful take-up of e-health services in Australia. E-commerce and its subset e-health are new and it is to be expected that changes will be needed to accommodate them. This need for barriers to be removed is in common with other sectors of the Australian economy, where the use of Internet technologies, in particular, is creating rapidly changing environments and new business models.

The Australian Government and industry need to continue to work together to ensure that high technology research and development leads to the rapid commercialisation of e-health technologies. Both parties also need to work together to grow Australian based technology companies in this area.

There is a need for industry leadership via a national and extensive group such as the Australian Information Industry Association (AIIA) and a strategic industry forum, which can provide a mechanism for industry discussions with government about solutions and trends. There is also a need for industry to work with health customers to build trust and work through the new business models emerging. A key finding since mid-1998 is the growing willingness of the industry (IT&T) and Internet technologists to work with their customers (health practitioners and clinicians) to develop solutions.

Unstoppable e-health

This report demonstrates that the term e-health is needed to describe practices that have become pronounced since mid-1998. This report specifically highlights a range of initiatives that use the power and reach of the Internet. E-health has arrived, it will continue to grow and it will bring benefits to Australians.

Australia's special challenges of distances and the undersupply of medical practitioners in rural areas are obvious incentives for expanding e-health. Other Australian drivers behind these developments include the realisation of the clinical benefits of using combinations of information and telecommunication technologies to provide improved or new services; the mounting pressure from consumers that the clinical world take advantage of the digital revolution; and the ubiquitous growth of the Internet.

The identification of these current e-health activities and the presence of these relentless drivers substantiate the title of this report, From Telehealth to E-Health: The Unstoppable Rise of E-Health.

Recommendations

It is recommended that:

1. Government, industry and stakeholders (including consumers and health professionals) work together to accelerate the widespread adoption of e-health practices, where it improves access to services and the efficiency and effectiveness of the health system.
   
   Key roles for the Commonwealth Government are the widespread dissemination of this report, the conducting of high profile workshops on the report and the use of the mass media to underline the importance of e-health.
2. Government, industry and stakeholders promote the emerging business cases and models for the development of e-health activities.
   
   The emphasis in these business cases will be on the use of  IT&T to improve the delivery of services to patients. New efficiencies, cost savings and changing business practices need to be highlighted.
3. Government, health professionals and industry partners target barriers to the development of e-health and promote ways to address them.
   
   Many of the barriers to the development of e-health can be removed, through policy changes, business strategies and the innovative use of new and emerging technologies. For instance, barriers that are now being addressed include concerns about privacy of health data; inter-connectivity between different technologies; the need for technical and clinical standards; and the remuneration of health professionals using e-health strategies. Another barrier is the low level of knowledge about information and telecommunications technologies among many health professionals. There is a need for training and development of e-health users and providers in the use of the Internet and other IT&T.
   
   There are many technical and regulatory solutions to overcome current impediments. Government and industry can also work together on industry development initiatives, such as research and development into new technologies and the availability of capital to support emerging Australian technology companies. Key initiatives such as the development of software applications and technical solutions for general practitioners need to be progressed immediately.
4. Federal Government agencies - the Department of Health and Aged Care and the National Office for the Information Economy - work with stakeholders including State Governments to promote the efficiency dividend from e-health for the economy at large. Particular focus should be given to the cost benefits of e-health in the home and the use of the Internet for healthcare.
   
   Cost benefit analyses of e-health can demonstrate the significant savings made possible by the appropriate application of IT&T. The cost benefit analyses can also demonstrate the improved clinical outcomes from e-health.
5. Telehealth and telemedicine advocates promote the integration of telehealth/telemedicine with the broader e-health and health reform agendas.
   
   E-health, as a branch of e-commerce, highlights the rise of customer demand, fuelled by the Internet and the potential applications of IT&T. High quality medical and health information can now be accessed via the Internet, and via IT&T applications, encouraging a surge in self-management and enhanced tools for use by health workers. Medical and health professionals can take advantage of this consumer interest in online information, by providing new services. Advocates of telehealth/telemedicine can promote both telehealth/telemedicine and the broader area of e-health.
6. Key industry groups or leaders provide leadership in the promotion of and strategic direction for e-health.
   
   The Australian Information Industry Association (AIIA) is a national industry organisation that is ideally suited to bring a sharp edge to the growing awareness about the value of combining IT&T for value added business processes in the health sector. NOIE should work with the AIIA to identify key industry stakeholders from the diversity of players who have participated in recent workshops. The AIIA should consider the formation of a permanent industry forum to champion the increased use of e-health and to address issues associated with vendor and customer conflict and distrust. The industry forum would work with Government, health professionals and stakeholders to address the range of regulatory, behavioural, clinical and industry development issues listed above.

RATIONALE

In July 1998 the Commonwealth Government launched Fragmentation to Integration: The Telemedicine Industry in Australia prepared by John Mitchell of John Mitchell and Associates. The report advocated that telemedicine should be integrated with the mainstream of health. The report also showed that many Australian telehealth activities are at the leading edge when compared internationally.  The results of the consultations were presented internationally at Telemed '98 in London in November 1998 and the presentation was adjudged the best when compared with findings from six other countries including Canada, Norway and Sweden.

Following extensive consultations and five national workshops to discuss the report in 1998-99, it became more apparent that it was increasingly difficult to argue that telemedicine or telehealth, in the sense of using "tele" technologies to deliver health services, was entirely discrete from the use of information technologies in the health arena. Hence the decision was taken to prepare this report to describe new and emerging practices in the health industry that use combinations of information and telecommunication technologies (IT&T). The research indicated that telemedicine or telehealth is now becoming part of a broader development that can be called electronic health or, in brief, e-health.

Explanation of e-health

The full definitions of terms such as telehealth and e-health are set out in the next chapter. Following is a brief summary of how e-health relates to e-commerce and telemedicine.

The period 1998-1999 has seen a significant rise in interest in the field of e-commerce, with the focus on business-to-business electronic communication. E-health is taken to be the health industry's component of e-commerce. E-health is a new term needed to describe the increasing use of electronic communication and information technology in the health sector.

However e-health is not simply about business transactions. This report shows that health industry practitioners are now using electronic communication for a variety of purposes besides business or administrative transactions. The case studies in this report demonstrate that e-health is the use in the health sector of digital data - transmitted, stored and retrieved electronically - for clinical, educational and administrative purposes, both at the local site and at a distance. E-health is now the term to use when describing the rise of digital technologies, electronic transmission and the convergence of technologies.  This term is all inclusive and captures the use of Internet technologies and the rise of the information economy.

Telemedicine is the term used to describe the use of telecommunication technologies for the provision of medical services to distant locations. E-health is a more general term that describes the use of both telecommunication and information technologies, for the delivery of health services both at a distance and locally. Hence e-health is the overall, umbrella field that encompasses telemedicine.

Aims

The aims of this report are:

• to educate readers about the increasing confluence of information technology, telecommunications and health care.
• to stimulate discussion and reflection about the opportunities for health that are raised by the information economy and the concept of e-health.
• to encourage further strategic analysis and direction setting for the information economy, in relation to health.
• to extend the messages from the 1998-99 Telehealth Workshops and the 1998 Commonwealth Government Report, Fragmentation to Integration: The Telemedicine Industry in Australia (Mitchell, 1998). In particular, to acknowledge those industry players who may not be receiving due recognition for their contribution to e-health (e.g. software developers; equipment suppliers; Internet-based providers; call centre operators).
• To advocate that it is in the interests of telemedicine and telehealth to be integrated with the broader, mainstream, movement to e-health.

Audiences and themes

This report will appeal to health industry participants and customers who are or could contribute to the development of e-health, including the many stakeholders represented at the 1998-99 national workshops. It will challenge but not threaten traditionalist thinkers, by emphasising the value of collaboration in the development of e-health.

Themes of this report include:

1. the relentless convergence of information technologies means that "tele" or telecommunication technologies will not be used in isolation from other information technologies. The report demonstrates that some practices that are currently described as telehealth are already using both telecommunications technologies and information technologies.
2. by positioning telehealth/telemedicine within the field of e-health, more opportunities and services will be provided in future.
3. the availability of new technologies provides opportunities to develop different paradigms about ways for consumers to access health services. New technologies also provide opportunities to re-engineer some health sector business practices, aimed at improving the quality of health care.
4. to realise these opportunities, there is an increasing need for the private sector to show initiative, to invest and to partner government. The case studies in this report demonstrate that the private sector is taking up this challenge enthusiastically.

Arguments

The study argues that the effectiveness of telehealth is currently limited by the positioning of telehealth outside of the mainstream of healthcare. Some critics perceive telehealth to be a peripheral activity and a novelty area for technological enthusiasts. The major cost benefits of telemedicine will not be realised unless this perception that it is an "add on" and an experiment is changed.

The study argues that with the relentless convergence of technologies and with the consequent increase in ability to perform multiple functions with those technologies, it is unwise to solely emphasise the distance factor, the "tele", in telemedicine. The combination of IT&T, of information technologies and telemedicine, is having a significant effect on healthcare.

This repositioning of telemedicine or telehealth as part of e-health will add to the justification of the importance and effectiveness of telemedicine and telehealth. It will also add to the expansion of telemedicine and telehealth beyond their current parameters. This report is not advocating an end to the use of the term telemedicine or telehealth; it is advocating that e-health is an important, overarching term.

The following case study is an example of clinicians effectively using both telecommunications and information technology during case conferencing.

Case Study: Renal Videoconferencing Combined with Local Network Data

Renal Unit Staff at The Queen Elizabeth Hospital (TQEH) in Adelaide, South Australia, can assess a range of medical images on the hospital network, for display during their weekly videoconferencing links to other hospitals.

Each Tuesday morning during the year, renal staff at TQEH are joined by their colleagues from the Royal Adelaide Hospital, the Flinders Medical Centre, the Women's and Children's Hospital, Royal Darwin Hospital and Alice Springs Hospital for live videoconferencing sessions. 

Dr. Merlin Thomas has developed a system where radiology and pathology images can be taken from the hospital network for display during the videoconferencing meetings. Data from the powerful patient database, Oacis, can also be captured and displayed. In particular, graphs can be shown that demonstrate the change of kidney function over time. Staff at the videoconferencing sessions can see a graphic presentation of a patient's timeline, with annotations of certain events and corresponding changes in transplant function. (Figure 1)

At the videoconferencing meetings, all the issues of renal transplantation are discussed including the assessment of potential donors and recipients and aspects of post-transplantation care. There is a particular focus on those who have recently received a transplant. Sometimes the patient has returned home to the Northern Territory and the staff who performed the transplant operation can discuss his or her progress. Both children and adult patients are discussed.

Figure 1: Timeline of Patient X

(sample graphic used in renal videoconferencing sessions)

 

During the renal videoconferencing session, each marker in the time line is illustrated by appropriate images embedded into the program  (for example histology images of renal biopsies performed, wound images, endoscopy images etc.). Graphs of other variables (e.g. serum cyclosporin levels) can be overlaid as appropriate.

Parameters of this report

When discussing e-health a vast range of topics could arise, such as the use of patient smart cards, the place of the electronic patient record and the development of infrastructure and standards to support electronic communication. This report does not attempt to address every aspect of e-health. It focuses specifically on the value of seeing telehealth as a subset of a broader field, e-health.

The following table summarises the parameters of this report.

Table 1.1: Parameters of this report

The following case study provides an example of the combined use of telecommunications and information technology in the nursing context.

Case Study: A day in the life of Nurse Heavensent

The Royal District Nursing Service in Victoria recently trialed the use of hand-held computers (PDA). Following are some examples of how fictional Nurse Heavensent used the PDA in one day to send and receive emails, check databases, enter data and keep notes. Each of the activities described below was achieved during the trial.

• Commencing her workday from home, Nurse Heavensent logs into the hand-held computer and checks today's schedule of visits. Using a mobile phone GSM data connection she connects to the organisation's mainframe client information system.  This allows her to check for emails and adjust visits, allocate a health aide to pick up one of her clients for today and check what equipment she needs to take to a particular patient.
• Setting off to see her first client Nurse Heavensent activates the hand-held computer to measure the amount of travel time.
• At the client's home, she uses the PDA to automatically measure 'visit time'; and enter data describing the visit activities.
• Returning to her car, she reads an email, which informs her that a colleague is ill and that she will need to visit another client. A 'Client Information Inquiry' message downloads the information about the new client. In response to another email, she also enters the discharge details into the PDA for a client who is about to enter hospital. Nurse Heavensent also sends an email to the liaison nurse working in the hospital, requesting follow up of this client.
• At a new client's home, the nurse enters Registration and Financial details into the PDA and arranges when the next visit will occur, entering this information into the scheduling module.
• Returning to the Centre at the end of the day, the nurse exchanges information with the mainframe client information system via a wire-less LAN connection.

The fictional case study is a composite of actual events during the trials. The case study demonstrates how a combination of information and telecommunication technologies can improve the efficiency of the nurse's daily work processes and bring immediate benefits to patients.

DEFINITIONS OF KEY TERMS

This chapter provides definitions of key terms relevant to this report:

• Telemedicine.
• Telehealth.
• Health informatics.
• Information economy.
• E-commerce.
• E-health.

The following table provides a brief definition of each term.

The discussion in this chapter will show that these six key terms, except for telemedicine, have only recently become common. While the terms are new, some of the practices are not: Health Online (1997) noted that "Telehealth has been practised via telecommunications technologies for almost one hundred years" (p. 9), through the use of telegraph, telephone and wireless. For instance, the Royal Flying Doctor Service has used these telecommunication technologies for remote diagnosis and prescribing treatment, only using the air evacuation service "in cases of serious care". (p. 9)

Each of these terms - telemedicine, telehealth, health informatics, information economy, e-commerce and e-health - was invented to define new practices and activities that were made possible by the invention and application of new technologies. As e-health is the newest term in this set, the definition of the term may change over the coming years. The following discussion of definitions locates e-health within this set of terms.

Table 2.1: Brief definitions of key terms

Term	Sample Definitions
telemedicine	"a system of health care delivery in which physicians examine distant patients through the use of telecommunications technology" (Preston, 1993)
telehealth	"health care at a distance" (Health Online, 1997)
health informatics	"an evolving scientific discipline that deals with the collection, storage, retrieval, communication and optimal use of health related data, information and knowledge" (Health Informatics Society Australia website)
information economy	"the new world of social and commercial interaction, brought about by advances in information technology" (Towards an Australian Strategy for the Information Economy, 1998)
e-commerce	"every type of business transaction in which the participants (i.e. suppliers, end users etc.) prepare or transact business or conduct their trade in goods or services electronically" (Australia's e-commerce Report Card, 1999)
e-health	"a new term needed to describe the combined use of electronic communication and information technology in the health sector - the use in the health sector of digital data-transmitted, stored and retrieved electronically-for clinical, educational and administrative purposes, both at the local site and at a distance" (From Telehealth to E-Health: The Unstoppable Rise of E-Health, 1999)

 
The following case study of Antarctic telemedicine is an example of capturing medical images with digital cameras, video cameras or a scanner and then transmitting them later using satellite transmission.

Case Study: Antarctic Telemedicine

Based on an article by Dr. Desmond J. Lugg, Telemedicine: Have Technological Advances Improved Health Care to Remote Antarctic Populations? in 96 Circumpolar Health, pp. 682-685

The Australian National Antarctic Research Expeditions (ANARE) were established in 1947. An excellent health care service has been established, despite difficulties in recruiting suitable medical staff and having only one doctor with each remote group, which is physically totally isolated for most of the year.

Medical communications have always been of utmost importance. Initially Morse code telegrams were sent over a HF radio system. Then twenty years ago, radio-telephone, telex, voice radio, and facsimile were available, but all were subject to the blackouts of polar cap absorption (PCA) for up to weeks on end. Today, using a satellite system, the following services are available: three-digit direct dial telephone service from the head office to any extension of any of the stations, telex, facsimile, electronic mail message and data transfer facilities, an image transfer system for sending photographs either taken on a digital camera or video camera, or scanned from a photograph taken by a conventional camera. This latter system transmits excellent images of diagnostic quality, of clinical and pathological problems, such as dermatological dilemmas, microscopic photographs of blood smears, x-rays, and ECGs.

Nations using telemedicine in Antarctica continue to use appropriate low technological systems. This does not mean that new developments are not introduced. If the existing medical system can be improved at cost effective rates, then changes are made, often riding piggy back on some research or communications development. An example of this is giving ANARE doctors (and all remote staff) access to the World Wide Web.

In Antarctica, systems have been sought and developed to solve the medical problems of isolation. Technology is very much the vehicle and there has been little reinvention of the wheel. Review of the varying practices, and specifically those of ANARE, answers the question posed: 'Have technological advances improved healthcare to remote Antarctic populations.' It is an emphatic "Yes." To the sole doctor without other medical staff, the changes have meant 24-hour access to specialists, the sharing of difficult medical problems, and the ability to improve diagnosis with clinical pictures, x-rays, and the like.

Telemedicine in the Antarctic has improved healthcare as a result of technological advances. It is hoped that this success can be used as a model for similar systems elsewhere.

Telemedicine

Preston (1993) provided a definition of telemedicine, which focused on doctors and telecommunications:

 a system of health care delivery in which physicians examine distant patients through the use of telecommunications technology. The term 'telemedicine' is derived from the Greek "tele", meaning at a distance, and from the Latin 'mederi', meaning healing. (p. 1)

After considering a range of definitions from around the world, Fragmentation to Integration: the Telemedicine Industry in Australia (Mitchell, 1998) defined telemedicine as comprising the following common elements:

• the delivery of health services (clinical, educational and administrative services).
• at a distance.
• through the transfer of information, including audio, video and graphic data.
• using telecommunications.
• involving a range of health professionals, patients and other recipients.

Telemedicine is sometimes defined in terms of the specific technologies used in the remote delivery of health services. For instance, Health Online (1997) defined telemedicine as 'the practice of medicine and delivery of healthcare between two distant locations by the use of interactive videoconferencing facilities.' (p. xii). The definition of "telemedicine as videoconferencing" was also found to be a common perception by Fragmentation to Integration: The Telemedicine Industry in Australia (Mitchell, 1998). When many interviewees for the report were asked what they understood by telemedicine they answered "videoconferencing":

videoconferencing has so dominated the health market in Australia, that some people not only see telemedicine as videoconferencing, they see telemedicine as represented by one brand of videoconferencing equipment. (p. 8)

It was argued in the report Fragmentation to Integration: The Telemedicine Industry in Australia (Mitchell, 1998) that the definition of telemedicine is under threat:

Telemedicine is a term under threat because of the inevitable convergence of technology, so that it will, in future, be difficult to separate telemedicine from other electronic healthcare activities. Telemedicine as a concept may eventually disappear, as telemedicine practices become part of mainstream health care delivery. (p. 3 )

The report also argued that 'we are on the cusp of the further and continuing expansion of the definition of the telemedicine industry'. (p. 8) The practice of telemedicine will increase, but its separate identity will become increasingly difficult to maintain.

These predictions about the pressure on the term "telemedicine" to be absorbed into mainstream health care delivery has been proved true perhaps sooner than expected, based on feedback from the national workshops conducted around Australia from late 1998. It became apparent in discussions and presentations at the workshops that telemedicine practitioners were beginning to combine their use of telecommunications with information technology and it was harder to differentiate the distance or "tele" component from the local site's use of information technology. The workshops are discussed in a later chapter of this report. The case studies throughout this report demonstrate the convergence of telecommunications with information technology.

Fragmentation to Integration: The Telemedicine Industry in Australia (Mitchell, 1998) noted that:

with the convergence of technology, particularly with the access to the electronic patient record becoming more and more prominent, it will be difficult to separate telemedicine from other health related activities that use information and communication technologies. (p. 6)

Fragmentation to Integration: The Telemedicine Industry in Australia (Mitchell, 1998) argued that, given the speed with which new technologies are being developed and the convergence of telecommunications and information technology at the desktop, and given the development of new paradigms about how healthcare can be delivered, there are two likely developments in the long term future:

• The practice of telemedicine will become more prominent.
• It will become increasingly difficult to differentiate telemedicine from many other uses of technology in the delivery of healthcare. (Mitchell, 1998, p. 6).

Call centres are an example of telehealth converging with e-health. Call centres rely on a telephone call for contact, but once the caller is linked to a nurse, the nurse usually accesses a powerful database on his or her local network. The argument in this report is that call centres are more accurately described as examples of e-health rather than telemedicine or telehealth, given this combined use of IT&T.

Telehealth

Fragmentation to Integration: The Telemedicine Industry in Australia (Mitchell, 1998) noted that in the last few years, the term "telehealth" has quickly grown in popularity, and telemedicine is out of favour in some quarters:

Telemedicine, for some people, suggests 'medicine' and therefore doctors and often males, while 'telehealth' includes all health professionals such as community health workers. This inclusiveness is an important issue: for instance, in some telehealth networks, particularly links to the patients' homes, the main users are nurses, not doctors; and in some mental health networks, the main users are psychologists, not medical doctors. (p. 4)

Fragmentation to Integration: The Telemedicine Industry in Australia (Mitchell, 1998) suggested that the new movement towards managed care, the promotion of wellness over treatment, and the concept of a health plan for life are all adding weight to the use of the term telehealth instead of telemedicine. Health Online  (1997), comments:

The Committee recommends the use of 'Telehealth' defined as 'health care at a distance' as a standard term within Australia and in international discussions and negotiations and considers that the term Telemedicine does not encompass the broad spectrum of health care delivered by the way of interactive videoconferencing technologies. (p. 8)

The definition used by the Telehealth Sub-Committee of the Australian Health Ministers' Advisory Council (AHMAC), the Australian New Zealand Telehealth (Telemedicine) Committee, emphasises health services, as opposed to medical services:

Telehealth or telemedicine is the name given to a health delivery system, which provides health related activities at a distance between two or more locations using technology assisted communications. (see, for instance, Swanson, 1999, p. 1)

The use of the term telehealth instead of telemedicine is favoured by those who wish to highlight the inclusiveness of 'telehealth' in contrast to the medical focus of the term telemedicine. The term telehealth will be used in the remainder of this report, as it is the more frequently used term in Australia.

Health informatics

The Health Informatics Society Australia website www.hisa.org.au defines health informatics as:

an evolving scientific discipline that deals with the collection, storage, retrieval, communication and optimal use of health related data, information and knowledge. The discipline utilises the methods and technologies of the information sciences for the purposes of problem solving and decision-making thus assuring quality healthcare in all basic and applied areas of biomedical sciences.

Emphases in this definition of health informatics are the scientific discipline and the methods and technologies of the information sciences.

It is argued in this report that many of the information technologies that health informatics professionals focus on are now being used in conjunction with telecommunications and Internet technologies.

Information economy

The technologies that have made telehealth possible are among a wide array of technologies that are changing jobs, communication patterns and aspects of our society and economy. Observers have coined the term 'information economy' to describe some of the effects of the technology. Towards an Australian Strategy for the Information Economy (Ministerial Council for the Information Economy, July 1998) defined the information economy as follows:

The new world of social and commercial interaction, brought about by advances in information technology, has come to be called the information economy. (p. 2)

The report documents a major shift in the way we live and learn and work in Australia.

It is part of a global change - the coming of the information society.

In Australia, and in many places around the world, students now use computers at home and school to research projects; governments supply information and services online, so that citizens needn't leave home to lodge forms or get the help they want; farmers access product information and markets by internet; people do banking - borrowing, transferring and investing money - electronically; businesses offer their goods and services for sale on websites, and consumers make purchases by browsing virtual shops and sending orders and payment over the net; friends and family members keep in touch with each other over long distances, by sending email messages; businesses exchange documents instantly and without paper; students do university degrees and professional training online; people interested in films, books, hobbies - anything - can meet like-minded people from around the world in chat rooms to share their interest. (pp. 2-3)

The report summarises the Government's vision for Australia in which all Australians have improved access to health, education and government services. Three specific health strategies include:

1. Using online technologies as an enabler to redesign information management practices in the health sector. Information technology offers unparalleled opportunities to knit together the communications and information sources of the many players in the health field, and to generate efficiencies in information management.
2. Expanding the use of online technologies to deliver better health services. There is already a substantial body of work in progress, involving all levels of government. In the long term, the government envisages an Australia where consumers and providers of healthcare, wherever they are located, have online access to clinical advice, specialist referrals, diagnostic tests, results and other telehealth services.
3. The expansion of markets for Australian online health services. (pp. 24-25)

The broad information economy has created the conditions for new ways of conducting business: electronic commerce or e-commerce.

E-commerce

Australia's e-commerce Report Card (Department of Communications, Information Technology and the Arts, April 1999) defines e-commerce as follows:

For the purposes of this report e-commerce is defined as every type of business transaction in which the participants (i.e. suppliers, end users etc.) prepare or transact business or conduct their trade in goods or services electronically. The scope of e-commerce is wide, covering all forms of electronic processes. Online technologies are the most significant facets of e-commerce and include Internet retailing, Electronic Data Interchange, Internet banking, electronic settlements and browsing and selection of products and services over the Internet. (p.3)

The report notes that there are several economic imperatives for increasing the uptake of e-commerce in the Australian business sector, such as:

• lowering the cost of doing business through lower transaction costs and faster and more efficient payment from suppliers and/or customers which increases cashflow.
• the competitive business advantages afforded by e-commerce such as opportunities to adopt new business models and to develop and tailor more efficient customer support.
• reductions in inventory lowering the holding costs of goods.
• expansion to potential market reach.
• increasing speed to market.
• "trickle down" effect through a supply chain as suppliers come online. (p. 8)

The report provided current data snapshots on e-commerce uptake from the ABS report Use of the Internet by Householder as follows:

• 1.27 million households were online as at November 1998 - a jump of almost 50 per cent in 12 months - giving 4.2 million adults access to the web.
• Nearly 930 000 households in capital cities had home Internet access at November 1998 (22 per cent of households in capital cities). This compares with 343 000 households in other areas of Australia (14 per cent of all households in these areas).
• Younger age groups had the greatest proportion of Internet users. Nearly 62 per cent (1.1 million persons) of 18-24 year olds accessed the Internet, for persons aged 25-39 years the estimate was 40 per cent (1.7 million persons). For persons aged 40-54 years it was 29 per cent and for persons aged 55 years and over it was seven per cent.
• E-commerce (business-to-consumer) is making slow progress over the Internet. Of those adults with online access, only seven per cent used it for commerce - or just two per cent of all Australian adults - to make around 1.2 million purchases in the year to November 1998. Less than one per cent used the Internet to pay bills or transfer funds. This contrasted with nearly 36 per cent who used a telephone, 61 per cent who used EFTPOS and 68 per cent who used an automatic teller machine.
• Those who used the Internet for e-commerce were relatively confident buyers, with 44 per cent having made a purchase in the past six weeks and 83 per cent paying for them online. About 36 per cent of purchases cost less than $250, while a third cost more than $500. About 64 per cent of persons undertaking purchases/orders via the Internet reported they had obtained them from overseas.

This sudden growth in the use of the Internet creates the necessary conditions for the inevitable take off of e-commerce.

The following case study documents an internationally recognised health online service.

Case Study: Continuing Medical Education On the Internet

CMENet is a Queensland consortium established to improve access to continuing medical education for regional, rural and remote rural health care providers via the use of distance education technologies, particularly the Internet.

The ultimate aim of CMENet is to provide more equitable access to quality health services for rural and remote communities. Workforce imbalances (including the dearth of specialists) result in the need for rural health professionals to acquire and maintain a broad knowledge and skills base. Hence CMENet addresses the twin challenges in rural medical education:

• meeting unique educational needs (not provided by traditional tertiary hospital and urban GP training models).
• overcoming the geographic isolation of these doctors and health professionals.

CMENet has three members:

• QRMSA is a collective organisation of rural GPs and is funded largely by the Federal Department of Health and Aged Care. It exists to improve recruitment and retention of rural doctors, thereby improving health services in rural communities.
• MICRRH. Mount Isa Centre for Rural and Remote Health has as its primary role the provision of education and training, in the fields of Public Health and Primary Health Care, on a multidisciplinary basis.
• RFDS. Royal Flying Doctor Service is the oldest, largest, most experienced and comprehensive aerial health and emergency service in the world. Its medical and nursing staff see more than 135 000 people per year. RFDS is responsible for the maintenance of skills of its staff.

CMENet exploits the Internet as the integrating factor in the delivery of relevant medical educational programs and resources. The CMENet website http://www.cme.net.au was developed to improve access by rural and remote practitioners to a broad range of educational programs and resources developed by QRMSA, RFDS and MICRRH. This web-based delivery and parallel CD ROM development enhance the other delivery technologies and modes used by members of the consortium, including case-based interactive satellite broadcasts (delivered nationally), videoconferencing, clinical attachments and skills-based workshops. CMENet enables the wide distribution of clinical information critical to safe rural practice, including clinical algorithms, new management guidelines and monographs on the "transfer of the critically ill patient". The web and the CD ROMs provide an enduring repository of information, relevant to rural practice, which can be accessed at any time. Learning is not dependent on attendance at an event fixed in space and time.

The choice of a variety of IT modes was influenced by an understanding of the "variability" of IT infrastructure available in the bush. Consideration of bandwidth constraints influenced web design. The availability of satellite receiving sites and videoconferencing sites were considered in determining delivery mechanisms. The imperative for CMENet is to develop programs which can be accessed locally and which meet the unique education and clinical education needs.

The CMENet website currently houses completed modules in Neurological Emergencies, which provides comprehensive clinical information on Management of Head Injuries: Seizures, Status Epilepticus, Meningitis, Head Trauma, Subarachnoid Haemorrhage, Coma, Care of the Cervical Spine. Resources from satellite programs on Retrieval, Neurology and Orthopaedics have been developed.

The Queensland consortium has been recognised nationally and internationally, as follows:

• publicised by Medical Observer (circulated to 20 000 doctors Australia-wide) as site of the Month - Dr F. Sim wrote, 'Continuous upskilling in emergency procedures, case management and retrieval are the linch-pins of this site. So if you wish to keep abreast of such information via the Internet, this is a very comprehensive site with a well thought-out approach to the subject'.
• selected by MedAu as site of the month.
• recognised by the American Journal of Anaestheology as one of the four best medical sites in 1998
• designated by National Heart Foundation (NHF) as online vehicle for educational resources for 'Heart Connection'
• recipient of Department of Health and Family Services (DHFS) grant to establish a national online calendar of events for rural doctors.
• designated as the vehicle for online delivery of education for Australian College of Rural and Remote Medicine (ACRRM) (accredited training). ACRRM is the world's First College of Rural Medicine.
• selected as the online delivery mechanism for 'public health training for clinicians'.

E-health

Electronic health or e-health is a subset of e-commerce. However e-health is not simply about business transactions. For the purposes of this paper, e-health is defined as the use in the health sector of digital data - transmitted, stored and retrieved electronically - for clinical, educational and administrative purposes, both at the local site and at a distance. Hence e-health is the overall, umbrella field that encompasses telehealth.

Fragmentation to Integration: The Telemedicine Industry in Australia (Mitchell, 1998) cited a number of major groupings of telemedicine technologies, for example:

• telephone, fax, and email technologies.
• videoconferencing technology.
• teleradiology technology.
• telepathology technologies.
• online health information, using the World Wide Web.

The case studies in this report provide numerous examples of health professionals and service organisations using combinations of the above technologies and other new technologies, to provide the following services:

• telephone call centres where the health professional operator has access to a powerful database.
• telehealth to the home involving both local monitoring equipment and telecommunication equipment.

Table 2.2: Two sets of technologies increasingly used in e-health

• teleradiologists using live videoconferencing and stored, digital radiology images.

This combined use of telecommunications and information technology justifies the use of the umbrella term e-health, in preference to telehealth.

Digram 2.1: Two sets of technologies in e-health

Besides this use of combinations of information and telecommunications technologies, the use of the Internet is starting to rapidly expand the reach of e-health. Case studies in this report record such Internet-based activities as:

• GP communication with hospitals and pharmacists via the Internet.
• Provision of professional development for remote health professionals using videoconferencing and the Internet.
• Patients communicating with health professionals via the Internet.

The previous case study on CMENet is an excellent example of an Internet-based health service.

The following case study is of a very successful health call centre that uses a combination of IT&T.

Case Study: Heartline

The Heart Foundation, one of Australia's leading charities, has turned to a fully integrated call centre to ensure that people throughout Australia can have easy access to reliable, accurate heart health information. Called 'Heartline', this national health information telephone service is the Heart Foundation's latest, and most responsive, weapon in the fight against cardiovascular disease.

Before Heartline was established in August 1998 people wanting heart health information often contacted their local Heart Foundation office. These calls were then handled, subject to the staffing and resources of the particular office. This could mean a call might be returned several days later when an appropriately trained staff member could address the inquiry.

The Heart Foundation relied on brochures and pamphlets, which are expensive to produce and distribute and don't address people's specific inquiries. The Heart Foundation was also very aware that people living in rural and remote areas have limited access to traditional sources of health information such as GPs and community health centres. The Foundation realised this had to change. Responses had to be immediate and the information given out had to be uniform and up-to-date. A high performance call centre was the answer.

Because most of the calls coming into the Heart Foundation relate to health, nutritional or research matters, quality was a paramount consideration. To ensure this, the Foundation adopted a combination of modern, powerful telecommunication technology with highly qualified health professionals and management techniques associated with a professional, commercial call centre.

Heartline is staffed entirely by Registered Nurses, some with extensive cardiac care experience, and fully qualified Dietitians, to provide instant advice and information to callers.

It must be noted that Heartline is not an emergency, diagnostic or counselling service. Heartline provides general advice on issues such as smoking cessation, physical activity, healthy eating patterns and cardiac rehabilitation.

Heartline is built around state-of-the-art computer systems and telephony IT systems to ensure quality. Access to the service is by a national 1300 number charged at the cost of a local call only, the number is then diverted to a number of phone carriers to ensure the Heart Foundation obtains the most economic call cost, regardless of the callers location. Once the call reaches the Adelaide-based call centre an Automatic Call Distribution system (ACD) places the call to an available operator. If all staff are on the phone, the caller is placed in a queue to be answered by the next available operator.

The Heartline manager uses Call Centre management software to constantly monitor demand for the service. This system is used to benchmark Heartline against commercial call centres by assessing caller average wait time, abandonment rates, talk times and handling times per call.

Computer technology is also used to support the staff members' extensive knowledge. While talking to a caller, staff members log the type of inquiry being made. The system then provides the nurse or dietitian with suggestions on appropriate publications to send the caller, or details of an external organisation that is located near the caller and can help or provide further information.

Heartline also embraces Internet technology. While at their workstation, Heartline staff can access information from various approved websites and they also handle all email inquiries generated from the Heart Foundation's own extensive Internet site. It is in this area that the Heart Foundation believes more advances will be made, with a direct 'chatting' style internet interface as the next logical step, should demand for such access continue to rise.

The use of technology to enhance the Heartline service also extends to mail fulfillment. Once a day the Adelaide-based centre uses email to send a database file to the Heart Foundation's national warehouse in Canberra. This file is then used to create 'picking slips' for the warehouse staff to construct specific information packages tailored to the callers' specific needs.

While Heartline uses many commercial call centre statistics to manage its service, it places less emphasis on factors such as operator talk time than many commercial operations. Instead Heartline focuses on providing reliable information and minimising the time callers wait for their inquiry to be answered.

Interestingly, Heartline is creating a greater understanding within the Heart Foundation of the needs and demands for heart health information. Before the call centre was opened it was difficult for the Foundation to report accurately on a range of factors, including the demand for health information, what topics were of specific concern to callers and what was the demand for service in regional areas. The Heart Foundation is already starting to use data collected by the Heartline call centre to review its current range of literature and position statements, to ensure information exists on topical issues.

Heartline's results speak for themselves. The centre has handled more than 20 000 inquiries in less than 12 months with 84 per cent of callers being able to speak to a qualified Registered Nurse or Dietitian within 30 seconds of dialling the centre's phone number. This number of people could never have been helped under the old system.

With very little promotion the centre has doubled the number of inquiries it has handled in the last six months. On average staff now take more than 160 calls a day and that is set to rise considerably. During the next six months the Heart Foundation plans to start a promotional campaign to ask General Practitioners to refer patients to Heartline if they require further information.

Customer reaction to the service has been very positive with many words of encouragement, support and a number of unsolicited donations being received. The Heart Foundation is very pleased with Heartline's initial results and the service is now seen as a key component of the Foundation's service to the people of Australia.

Heartline staff trained in nursing provide service to customers.

The following diagram graphically describes the relationship between the different concepts discussed in this chapter.

Diagram 2.2: Relationship between key concepts

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