Drivers of broadband in health

There are three main drivers of broadband take-up in health: clinical applications, education and professional development, and electronic management of patient records. There are over 600 sites nationally currently delivering technology-enabled health services, although few are using broadband. During NOIE consultations it was indicated that the current use is split into around 25 per cent clinical; 50 per cent education and professional development and 25 per cent administration and management.

Clinical applications

Clinical applications are those services provided by a medical practitioner to a client or when acting in a consultative capacity to another medical practitioner often in a remote area. These include diagnosis, treatment, medical tests (such as pathology or radiology), surgery, post-operative consultations, on-going treatment or monitoring. The benefits of the use of online technologies in clinical applications include:

• more timely health care;
• improved access to care, including specialist care;
• decrease in unnecessary referrals;
• reduced travel and reduced cost; and
• possibility of local treatment and/or early return to the local community.

These clinical applications using online technology deliver productivity benefits in terms of improved health outcomes, savings to the health budget and time and cost savings for individuals.

Remote surgery

Remote surgery is the application that most convincingly demonstrates the need for reliability of the technology and high bandwidth required in health applications. While still in the 'brave new world' category in terms of usage, telesurgery became a reality in September 2001, when surgeons in New York removed the gall bladder from a patient in Paris. The procedure was performed using robotics while a doctor at a remote location provided commands. Although still not commonplace, there have been advances in minimally invasive surgical techniques combining robotics, artificial intelligence and other technology to replace traditional surgery.

Remote consultation

The most common online application is to provide a patient consultation at a distance, generally using videoconferencing or some form of data sharing.

A leading edge example is the virtual emergency room currently being developed as part of the CENTIE advanced networks project in conjunction with the Nepean Hospital. A similar virtual intensive care unit, TARDIS, was implemented in Queensland in 1995-98, using less advanced videoconferencing technology. The use of a fully interactive broadband connection enables the consulting expert medical practitioner to have multiple camera views of the patient as well as the doctors and nurses in the emergency room, to control zooming and panning and to monitor vital signs and test results which are displayed on the screen. This enables the remote expert to direct the activities of the emergency room staff. It also demonstrates the more critical need for reliability in health applications.

A more common example is ophthalmology, which has been successfully undertaken around Australia albeit within the limitations of narrowband. A trial of remote ophthalmology for acute eye cases and postoperative review in Mt Isa, Queensland, in 1996-97 resulted in proven travel savings of $16,500 over a three-month period.

The Bayside e-Health Unit, based at the Alfred Hospital in Victoria and which encompasses the Caulfield General Medical Centre, has reduced travelling for outpatient visits between these sites. This reduces costs and makes available valuable ambulance resources for emergencies rather than transporting patients between the two sites. The unit also involves 11 hospitals in the Gippsland region, with the main aim of providing timely intervention in trauma cases, thereby reducing the incidence of unnecessary helicopter evacuation because of a lack of access to specialist diagnosis.

Videoconferencing has been used for telepsychiatry services for many years and delivers more timely intervention as well as cost savings, because the client does not have to travel for the consultations. The quality of the facilities available varies significantly in different locations, forcing people to work around the limitation of slower connections or end terminals with less sophisticated features. However, this does not change the fact that the concept of psychiatric consultation at a distance is now accepted when an in person consultation is not possible. (More detailed information on telepsychiatry is provided in the Rural and Remote Mental Health Service of South Australia case study at appendix A)

Teleradiology

While it is possible to send x-ray images over a narrowband link it will take longer for the transmission of a large data file and the specialist and the local practitioner will not be able to interact with the data at the same time. If a broadband link were used it would be possible for both doctors to view the images virtually instantaneously. With the use of shared image software one doctor can point to a feature on the image and the gesture can be seen at the remote location. This kind of real time interaction between practitioners would vastly improve the process of seeking a second opinion or specialist input remotely.

Teleradiology facilities are more specialised than the standard videoconferencing units used in telepsychiatry therefore the practice is currently far less widespread. There are projects in Australia to implement digital radiological systems within particular hospitals to facilitate the immediate availability of images whenever and wherever they are needed. For example, the Canberra Hospital is setting up such a system and the Women's and Children's Hospital in Adelaide has been using teleradiology since 1998. The trial in the Women's and Children's Hospital in Adelaide uses 128kbps ISDN lines to link remote hospitals to Adelaide. The trial demonstrated the effectiveness of teleradiology although using narrowband. While some of the benefits of the system were difficult to quantify, there are clear cost savings when patients were not transferred unnecessarily.

Remote monitoring

The capacity for people to remain at home and have quick access to assistance when required is likely to become increasingly important as the 'baby boomers' age. In 1976 Australia had 1.3 million people over 65 years of age or 9 per cent of the total population. By 2001 this had increased to 12 per cent and projections indicate that by 2016 there will be 3.5 million or 16 per cent rising to 6.03 million or 25 per cent by 2051. This will present a significant challenge to the health system. The Government has identified as a key priority developing an affordable and effective residential aged care system that can accommodate the expected high growth of older people. Remote monitoring should be a key element of a strategy to implement this priority.

The CSIRO Hospital Without Walls project has developed technology to assist the elderly and chronically ill to remain at home while being continuously monitored. Using a small, wireless device that is worn by the patient, the vital signs and movements of the person concerned are recorded by a local computer and sent to the appropriate clinicians, nurses or caregivers via a distributed information system. The device is designed to use standard telephone lines, which limits the amount of information that can be collected and transmitted. This kind of system can assist in keeping people out of hospital or nursing homes, reducing costs and improving the quality of the person's life. It also potentially improves health outcomes for people by providing necessary assistance when it is needed and allowing medical professionals to respond quickly to a change in a patient's condition. With a broadband connection, more information could be sent in real time to medical practitioners making it a possible option for a wider range of patients.

Education and Professional Development

Educational and professional support systems ultimately have beneficial clinical outcomes in that they produce more highly skilled medical professionals and provide information for better decision making. This is of particular significance in rural and regional areas, where the quality of professional development and skilled support in diagnosis would be a key factor in attracting skilled professionals.

Training

The Collaborative Training and Education Centre (CTEC) at the University of Western Australia is one of the world's most advanced medical and surgical skills training facilities. The Centre works in partnership with CSIRO and a private company, MedicVision. Technology is being developed to make it possible for students to practice on 'virtual' patients. The system uses 3D visualisation and a force-feedback robotic arm that simulates the sense of touch (a 'haptic' workbench) to provide an immersive virtual surgery environment. Using this kind of virtual environment it is possible to represent an exact situation and 'experience' it, providing the sense of touching, cutting or manipulating the objects involved. This virtual environment overcomes limitations in the use of cadavers and allows multiple practice of the same procedure at a much lower cost.

This environment is experimental and challenges such as the development of appropriate software to simulate a range of surgical procedures need to be addressed. Although at a developmental stage, CSIRO has demonstrated collaborative use on a gall bladder simulation between two sites. Participants were able to interact as though they were in the same room using videoconferencing and the haptic workbench, including virtual touch. This application was demonstrated using a 10 Gigabit per second Ethernet network. This very high end broadband network was necessary for such a data intensive application to be performed interactively in real time.

While this technology offers great opportunities to train surgeons in facilities such as CTEC and over high speed networks at any appropriate location, it also offers the possibility of tracking the progress of students. The system is able to record the accuracy of the procedure, the angle of entry of an incision and the amount of tissue damage, allowing a student to know when skills are improving.

CTEC has also utilised videoconferencing facilities to link world specialists in particular fields with multiple locations throughout Australia to offer very specialised training. While issues such as dealing with different time zones need to be managed, this facility provides access to valuable specialist information to people in a wide range of locations at once. The skill sharing that this provides leads to better health outcomes in widely distributed locations with cost effective delivery.

While it is exciting to have a leading-edge training facility developed in Australia it is important to note that there are also a number of facilities that use traditional videoconferencing to deliver training workshops to remote locations, including the Bayside e-Health videoconferencing system described earlier.

Online databases

A simpler but still important application of broadband is in the area of information access. Metropolitan medical practitioners have had access to journals and decision support databases and software in recent years. The access for regional and remote practitioners has been problematic because the highly interactive nature of searching for information in large databases requires high speed connections to be effective. Distributing the data, for example on CD-ROM, is less effective than a centralised information system as it will not be possible to have the latest information always available on this kind of distributed media. One of the main advantages of these interactive databases is the ability to access the latest information on a particular topic.

Availability of accurate information at the exact time and place critical medical decisions are being made can improve health outcomes. In April 2002 Canada began a trial using wireless hand-held computers in the emergency departments of hospitals in British Columbia. These devices are designed to provide emergency room physicians with solutions to day-to-day pressures they face in providing fast accurate diagnosis by providing access to online information from journals, reference books, online data services, web site, and drug information and treatment protocol databases. The benefits expected in the Canadian pilot project include reduced risk of errors in diagnosis and treatment, fewer hospital and doctor return visits, and less pressure on emergency departments.

A similar system is being established in the South West Alliance of Rural Hospitals (SWARH) in Victoria. SWARH is making use of its broadband network for wireless applications in the hospitals as well as a range of other applications (more information about the SWARH network is available at appendix A). Doctors and nurses are using handheld wireless devices in current trials to update patient records in a central database from the bedside. This means that the same information is available to the doctor in the office or at the patient's bed. That information is recorded centrally, reducing errors that can occur when information is recorded and stored at different locations. These wireless applications could use a narrowband wireless local loop when only a small number of users are involved. However, when information is required by many users, for example in a hospital situation, broadband network infrastructure is needed to allow for fast concurrent access and the immediate update of information.

Other Applications

Other applications range from centralised electronic patient record systems and billing, to the telephone systems used by the practitioners. There are obvious business efficiencies to be gained from improvements to these administrative systems. There are readily identifiable clinical benefits, especially in terms of better health information and reduction of errors.

Electronic patient records

The issue of individual patient records is becoming increasingly more challenging in the contemporary health environment in which services are complex, distributed and where people are more mobile. It is important to be able to identify health consumers uniquely and reliably.

All Australian Health Ministers, at both a Commonwealth and State and Territory level, have recognised the importance of the transformational change possible by an integrated system. They are working collaboratively to establish a national electronic health information network - HealthConnect. Initial trials will start in the Northern Territory and Tasmania by the end of September 2002 and will run until June 2003. Larger tests will also be conducted in Queensland and New South Wales after the initial trials. This network is designed for the collection, storage and exchange of patient health information with strict privacy safeguards. It aims to improve continuity of care for people when they seek treatment in different locations by providing the medical practitioners with access to the same information wherever they are.

This is particularly useful with patients such as diabetics who often have complex care arrangements, or others who take a range of medications which it is hard to recall when needed. The work on HealthConnect also involves looking at attempts to set up electronic health records around the world.

The use of wireless handheld devices, such as palm pilots, by medical practitioners visiting patients in their homes or in remote sites, can also improve efficiency. A trial with district nurses in Victoria in 1999 demonstrated potential benefits of such a system if it was implemented more widely. These types of activities all save time and money and allow all of the appropriate health care professionals involved in a case to access completely up to date information at any time.