Impediments

The consistent message that NOIE received during consultations for this paper was that availability of broadband at an affordable price was still the major impediment to more widespread use in the health sector. One of the factors contributing to this problem in the health sector is the perennial dilemma of budget prioritisation. Without specific allocation of funding for capital and recurrent expenditure on information technology costs, health care institutions are effectively placed in a position of 'Solomon's choice'. That is, funding for information technology generally comes at the expense of a reduction in funding for traditional core business activities, such as hospital beds or additional practitioners.

In addition to the crucial supply issues, impediments range from the management of the cultural change process for medical practitioners, to privacy concerns, to the Medical Benefits Schedule and medical legal issues. While none of these issues is insurmountable, they require careful consideration in the implementation of broadband health services.

Availability of Broadband

Broadband communications are available using a range of technologies. While there have been advances in the roll out of networks for the delivery of broadband, access to appropriate broadband networks continues to be an issue for the health sector.

The backbone network, which links major cities, is mainly a fibre optic cable network. The National Bandwidth Inquiry found that there is sufficient backbone capacity in and between major centres, particularly on the east coast. However, there are few spurs off the main backbone into regional areas and the 'last mile', the connection from the backbone (usually at a local exchange) to the premises, is expensive in both metropolitan and regional areas. Issues of availability are therefore not consistent throughout Australia. There are limitations in the fibre backbone in places such as regional Western Australia and there are other limitations in the availability of spurs for access to regional centres from the east coast backbone.

The types of technologies that can supply last mile broadband communications capacity are varied and each type has its own benefits and limitations. ADSL (and other forms of Digital Subscriber Line technology) and cable are the most common technologies in metropolitan areas. Leased lines (ISDN) provide narrowband connections in many places but this has limitations. Satellite is, technically, available everywhere. Wireless is a possibility in the future but is not currently widely available as a commercial offering.

All of these technologies have their limitations. Of most concern from the point of view of health services is the asynchronous nature of ADSL and one-way satellite, which limits the use of real-time interactivity. Satellite is further limited by high latency, which also creates difficulty in interactivity. Cable is limited by its rollout, it has to pass your premises to be available and is less likely to be rolled-out in regional areas because of cost. Wireless is sometimes limited to line of sight, those systems that do not require line of sight often do not supply high bandwidth because of the frequency used.

Affordability of Broadband

Many of those consulted by NOIE in the development of this paper indicated that affordability is a key issue for the health sector. However, different aspects of affordability were highlighted in different states. The way in which funding is allocated can often be a major impediment to broadband expenditure. In budgets it is hard to justify expenditure on broadband investment when the money could be allocated to what is perceived as 'core business', such as more hospital beds or additional nurses. This is especially true when the business case for infrastructure is calculated as an adjunct to a single application, therefore the infrastructure expenditure has to be factored into an individual cost benefit analysis. Where this constraint is absent, for example in a new hospital where common use infrastructure is provided - as it was in St Vincents in Victoria, it is much easier for departments to prove the business case of an application.

Expenditure on broadband, to provide better quality of service or an extended range of services, can expose service providers to harsh criticism about priorities. During consultations NOIE received mixed messages about the relative difficulty of funding capital expenditure and recurrent costs. Some believed it would be possible to cover recurrent expenditure but impossible to manage the initial capital outlay associated with establishing the networks and purchasing the end use equipment. Others found that the ongoing costs of use would be restrictive.

Current public funding arrangements can leave health service providers without reimbursement for ICT investment and services, but fully reimbursed for traditional inputs. This provides incentive to health service providers to use traditional (possibly higher cost) service delivery mechanisms rather than ICT.

Affordability can be a problem particularly in regional areas where the range of current broadband technologies is limited. While satellite offers ubiquitous access it is currently vastly more expensive than other broadband options and its current higher latency and asynchronous functionality may offer poorer quality of service for health.

In some cases the value proposition of the substitution of an ADSL or some other broadband connection for the lease of multiple phone lines and the associated call costs, makes broadband a sensible choice. A greater awareness of the services available, coupled with an analysis of the real costs associated with current practices, could provide a convincing business case in many instances.

Standardisation and Interoperability

The investment case for broadband in health is usually developed as an adjunct to a specific application. However, the common use nature of this infrastructure requires a different investment paradigm. A recent UK study identified that inadequate setting of ICT standards from the centre has resulted in a diverse range of incompatible systems across the health service and resources being wasted on 'reinventing the wheel' at a local level. Similar issues of standardisation of infrastructure and applications to ensure interoperability and access have been identified in Australia. The UK study suggests that a national, integrated ICT system across the health service can lay the basis for the delivery of significant quality improvements and cost savings over the next 20 years.

Reliability of Broadband

There have been quite widely reported reliability issues with ADSL leading to a public perception that the technology is not fully mature and is unreliable . The system uses new equipment and software products that have had problems. Telstra has announced a Customer Service Level Guarantee that will operate from 1 July 2002, which provides a partial rebate to ADSL customers if the availability of the service falls below 99 percent in a month. However, even if the performance of an ADSL service met Telstra's published minimum standards of being available 94 per cent of the time, it would be inadequate for many health applications. The partial compensation offered for availability below 99 percent in a month has no relevance in the health sector for mission critical applications. There have also been issues with leased lines. Examples of flooding or accidents disabling all communications to regional and remote areas are not uncommon.

These types of reliability issues are of serious concern. While unreliable connections can be annoying in other sectors, in health, when information is needed at the time of the issue and delays can literally be life threatening, reliability becomes paramount. Even in cases where the consultation was routine, it has been found that medical practitioners will be unwilling to use the facilities in the future if they did not work well every time they were required. They would prefer not to bother with a system that is not always available. Of course a reliable broadband network is critical in the high-end systems such as surgery using robotics. Any kind of technical delay or outage would be catastrophic.

Reliability problems are difficult to solve. The real solution to many issues of reliability is redundancy in the network. This would generally require paying for a second line or an additional backup service of whatever form. For some applications this would be justifiable, in other cases the cost of failure is less than the cost of redundancy. Additional infrastructure is required to provide redundancy and this will not always be available in the places it is needed, especially when availability of any service remains an issue.

Additional Technical Considerations

Technology-enabled health applications are most beneficial when they facilitate real time interaction. This demands particular technical requirements that may be less important in some other kinds of broadband applications. Health needs low latency and synchronous links to facilitate effective real time interaction. This limits the effectiveness of some technical solutions such as satellite.

An often-cited problem is in obtaining access to appropriate technical support for the network and the equipment for medical professionals who are not familiar with information technology systems. The Rural and Remote Mental Health Service in South Australia has overcome this issue by providing a central support person and having maintenance and service contracts with equipment suppliers in the regions. The Divisions of General Practice have been able to provide technical support through funding provided by the Commonwealth Government.

Applications Development

Many health applications are currently being run or developed for narrowband environments and this is limiting benefits and suppressing the real demand for broadband communications in the health sector. Some of the applications of information technology in health do not require any communications component, for example when the computer with the analysis software is physically connected to the medical test equipment. However, for less specialised equipment it is useful to be able to transmit the information from testing for a specialist opinion, be it across a hospital, across town, across the country or around the world. If the software is expensive or requires specialist skills it may not be practical to distribute it widely. Transferring information and results may be the best way to use the technology more broadly.

Tele-ultrasound applications that fall into this category have been developed by CSIRO. The ultrasound equipment is widely available and relatively inexpensive, but rural medical practitioners may not be skilled in the highly interactive procedures. While telemedicine would be an appropriate way to address this issue, it has been found that transmission of high quality images in real time is prohibitively expensive. The system was developed to use proprietary compression technology so an effective image can be shared in real time over a 128kbps link with feedback from specialists provided by a voice connection. Another example is a wound imaging system developed at the Alfred Hospital in Melbourne - the software can use low quality digital images that can be transferred easily via e-mail over existing telephone networks.

The development of applications that either specifically cater to the limitations of a narrowband communications network, or are limited in their functionality because of a perceived need to rely on standard telephone lines and modems is likely to be suppressing the real level of demand for broadband services in the health sector.

Security and Privacy

The sensitive nature of personal health information increases the significance of security and privacy issues. They are difficult problems, but they have known solutions.

Security procedures and facilities such as physical security, information management procedures, screening of staff and reliable identification of clients are required when dealing with any health information. With the addition of a broadband telecommunications network, security is complicated by the presence of communication links and geographic separation adding further opportunities for unauthorised access to the information.

The privacy of communication across a network will not be guaranteed without special measures being taken. Protocols exist to secure digital information in communication and storage, and to reliably identify the users of a service or the participants in a conversation. Cryptographic digital signatures can be used in the same way as a pen-and-ink signature - to reliably assure the authenticity of a message, document or statement.

While security of a broadband network may be difficult and expensive to implement, it is a solvable problem. Public key infrastructure (PKI) mechanisms provide a framework to guarantee the identity of individuals or service providers and to guarantee the authenticity, integrity and source of communications (this encompasses systems that collect evidence to support non-repudiation: the inability of the source of a message to successfully dispute the authenticity of the communication). A wide range of encryption protocols also provides for privacy of communications.

Progress with Privacy legislation

Privacy legislation compels organisations using personal data to implement security and privacy procedures. The Commonwealth Privacy Act 1988 lays down strict safeguards which the Commonwealth and ACT government agencies have to adhere to when collecting, storing, using and disclosing personal information. In December 2000 the Privacy Amendment (Private Sector) Act 2000 was passed and came into effect in December 2001. This set out rules for the appropriate handling of personal information by private sector organisations. The Federal Privacy Commissioner also issued Health Privacy Guidelines in November 2001 to assist health sector organisations in meeting their obligations under the new legislation.

In addition to this Commonwealth legislation the ACT, Northern Territory, NSW and Victoria have introduced legislation specific to the privacy of health information. This legislation applies to both the public and the private sector. Compliance with all of these pieces of legislation when using broadband communications in the delivery or support of health services will require the implementation of appropriate security processes.

Progress with Public Key Infrastructure

The Health Insurance Commission has made significant progress implementing Public Key Infrastructure for electronic security for the health sector in Australia. It has established PKI to allow practitioners to access the HIC services. The Commission has also established the Health eSignature Authority, which is an independent registration company to facilitate the introduction of Public Key Infrastructure (PKI) into the health sector. An Online Medicare claiming web browser facility enables patients to have their Medicare claims lodged electronically from their doctor's practice, using their PKI system. The HIC is also able to provide the IT standards required for electronic transmission, scanning and storage of Referrals to specialists/consultant physicians and requests for pathology and diagnostic imaging services.

This infrastructure provides a way forward for the privacy of health information transmission, dealing with the system security and implementing the appropriate privacy standards. The HIC has done significant work on educating users about the importance and appropriate use of digital signatures to ensure an understanding of the legal significance of a signature and procedures for protecting its integrity. However more work is required in modifying existing information systems to incorporate security mechanisms, including network systems and application software as more applications are developed.

The HIC effort has concentrated on its core business of Medicare claiming and referrals. Clinical systems also require these high levels of security and privacy. These systems are by and large handled individually and security can still be a serious issue in these systems. As the implementation of the HIC PKI progresses, the same infrastructure should be able to be put to use for clinical applications.

Cultural change

Some medical practitioners have been reluctant to take up online technologies, while others embrace the new technology with enthusiasm. In this they are no different from other segments of the population in dealing with new technology. The key to acceptance is managing the change process and providing adequate skills development and training.

One key to acceptance is demonstrating the benefits and allowing medical professionals to request the kinds of services they would find personally beneficial. This was the approach taken by the South West Alliance of Rural Hospitals (SWARH) in Victoria. They achieved high levels of acceptance of the new technology available through their communication network by providing the services practitioners requested as a first priority. This bottom-up approach allows practitioners to feel that the technology is working for them rather than the other way around.

Regional practitioners have been reluctant to accept e-health practices because they are seen as a potential substitute for visiting specialists. Acceptance has been better in situations where e-health services have been used to augment existing services not as a replacement, such as the South Australian telepsychiatry service. These services were met with initial scepticism, but once it became clear that they were not replacing the existing visiting specialist service the technology was accepted.

General practitioners have been encouraged to use computers in their practices through incentives being paid for the use of a computer in the practice and for connections to the Internet. This system has been very effective, increasing computer use to over 80 percent of GP offices. Similar encouragement could be used to move the large number of GPs to broadband services and other relevant applications such as electronic patient records. Surgeons are often less reluctant, possibly because they use high tech implements in their work, making them more accepting of new technology.

Another area of important cultural change is the requirement for changes to work practices when dealing with electronic data and security. These changes are difficult to implement and will vary between small area health services, GP offices and large hospital environments.

Medical Benefits Schedule

There are no e-Health services listed in the Medical Benefits Schedule (MBS), other than imaging services, although a proposal for listing telepsychiatry is being considered. The lack of Schedule items was cited as an issue in many of our consultations.

The telepsychiatry service offered through the Rural and Remote Mental Health Service of South Australia overcomes this through State government funding paying directly for the consulting psychiatrist's time, and the local (rural) health practitioner claiming for the consultation through the MBS. Eight psychiatrists are employed by the service and are rostered on for four sessions a day using two videoconferencing rooms in Adelaide to connect to some 65 units throughout the state. When they are not involved in videoconferencing sessions these consultants work in the Adelaide ward facility. Without this state government funding the Rural and Remote Mental Health Service would not be able to offer the telepsychiatry service.

It is possible to use the 'case conferencing' item in the MBS for some e-Health services, however direct reimbursement for e-health would promote its use.

Medical Legal Issues

Legal ramifications of consultations at a distance and the issue of indemnity for those offering advice are of concern to medical practitioners.

Issues such as licensing for consultation across state and territory boundaries have been overcome by some individuals through registration in multiple states. A national registration mechanism for online health services would facilitate its wider adoption.

Medical indemnity is a difficult issue in the present circumstances, but standards and recognised status for e-health services should be able to overcome difficulties in this area over time.

Overcoming Impediments - An Example of a Private Network Solution

A number of approaches have been taken throughout Australia to overcome the impediments to the uptake of broadband in the health sector. The establishment of a network by the South West Alliance of Rural Hospitals (SWARH) network in Victoria, designed to overcome supply issues, is worth looking at in greater detail.

SWARH built its own microwave based network with a wireless or fibre optic local loop providing the last mile solution. This required agreement to a significant capital outlay each year for the first five years of the network's operations The actual network required a recurrent lease cost of $0.6 million per annum. The capital works were substantially completed in the first 18 months and involved ensuring each site had state of the art networking and could participate fully in the broadband facility, this included purchasing a common patient and finance system for all sites.

Projects which were to be delivered over the 5 years (this is the 4th year of implementation) included Internet, email, IP based videoconferencing and the replacement of 9 hospital telephone systems with a single IP Telephony system located at the hub of the network. The business case presented involved replacing the existing telephone and data networks linking the hospitals in the region together and to Melbourne. The aging PABX systems were due for replacement and therefore building a broadband network that could deliver voice over IP and make the PABX redundant was an appealing proposition. It also means that the network costs for videoconferencing between the sites is minimal.

The broadband IP (Internet Protocol) network that was put in place by AAPT has generated significant savings for the hospitals and other health sites connected to the network in the region (33 sites in all).

The administrative arrangements for the health sector in Victoria in which regional alliances are autonomous in their operations facilitated this solution. In addition, the region has a density of population centres large enough to support this solution. The region covers approximately 50,000 square kilometres, with distance between sites ranging between 30kms-280kms. The largest centre has a population of 30,000 and the smallest around 500.

While some other states are investigating the feasibility of similar arrangements, it may not be possible because of more dispersed regional settlements (particularly away from the coastal areas), state contracts with carriers and centralised administrative arrangements in the health sector. The 'arms-length' administrative arrangements with government enabled the SWARH hospitals to develop an innovative solution and demonstrate a 50 per cent reduction in the targeted costs. This convinced the government and the contracted carrier to adopt the solution.

Other possibilities, such as leveraging networks set up for education or judicial applications, are also being examined as possible solutions to supply dilemmas. Aggregation of demand in government services is another mechanism that has been implemented with varied levels of success. SWARH has now moved from just a hospitals solution to an 'all of Health' model which includes local Government. The success of this model will make the SWARH network sustainable by the agencies without additional Government support. Clearly, aggregation of Education, Police, and Justice would be the next step.