With global healthcare systems feeling the strain of soaring costs and stretched resources, information and communication technology is being touted as a much-needed remedy.
The cost of healthcare is one of the great riddles of economic management. In industries ranging from food to cars to telecommunications, things are getting better and cheaper. Not in healthcare. In Australia, for instance, healthcare costs have been rising by more than 5 per cent annually in recent years – almost double the pace of growth in the economy generally.
So fast are costs escalating in advanced economies that the Organisation for Economic Co-operation and Development predicts that, without reform, healthcare will be unaffordable by mid-century.
In seeking to fix this problem, experts are looking towards telehealth – using information and communication technology to deliver healthcare.
Telehealth encompasses all sorts of technological health solutions, from sophisticated in-home remote patient monitoring hardware to a simple SMS from a concerned parent to a general practitioner (GP).
Dr Tori Wade, a University of Adelaide research fellow who edits the Journal of Telemedicine and Telecare, gives the example of a patient with a chronic condition who steps onto an internet-connected weight scale every morning. A remote system can analyse and store their weight, and if it suddenly spikes – a sign of dangerous fluid overload – their medication can be quickly adjusted.
Such technology can not only reduce the costs of existing health procedures, but also improve on them. Dr James Freeman, a Tasmanian-based GP and founder of telehealth start-up GP2U, is one of many who argue that telehealth’s biggest boon is its potential to deliver the right care at the right time – sometimes well before a patient would have made a trip to a doctor.
In the waiting room
Some countries have made more progress than others on telehealth. Denmark’s national telehealth portal has been providing access to healthcare services for citizens and health professionals since 2005, and China is on track to become one of the largest telehealth markets in the world.
In the US last year, 42 states introduced more than 200 telehealth-related pieces of legislation, while the Canadian Government has injected more than US$2 billion into 400 telehealth projects across the country’s provinces and territories.
Despite all their efforts, however, almost no country has succeeded in using telehealth to cut costs and make healthcare more efficient on a large scale. It is the remedy that remains tantalisingly out of reach.
In Australia’s generally well-regarded health system, telehealth has been a policy item for decades. It has particularly been seen as a means of delivering efficient healthcare to the far corners of Australia and to the ageing population. At the same time, however, it has been plagued by issues such as privacy concerns, worries about the adequacy of broadband and a lack of appropriate skills among healthcare professionals.
A series of pilot programs has underlined the difficulties of making the technology deliver better outcomes. The joke in Australian medical circles is that telehealth has had more pilots than Qantas but has never been able to take off.
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If you ask Wade, the problem lies with the fact that the entire system gets in the way of telehealth. “People say technology has worked for finance and retail and travel, so how come health is lagging so far behind with the uptake,” she says. “It’s just not a simple substitution. We need to go back to scratch. We need a whole new model of care.”
Australia’s current public healthcare model sees patients placed on sometimes lengthy waiting lists or travelling great distances for specialist treatment. Wade cites the model for chronic pain management as an example.
“A GP gets to the end of their skills and ability to manage the patient, refers them to a specialist and they may have to wait for two years. It’s not uncommon to ask someone with chronic pain to wait that long,” she says. “I would contend that [the existing system] is failing patients dismally – not because the quality of care is bad but because it’s inaccessible.”
Freeman also points to the shortage of GPs in Australia’s rural and remote locations. “There are fundamental inequities in healthcare access and outcomes between city and country,” he says. “There is one doctor per 1000 people in the city and one doctor per 3000 in the country. Earlier appropriate care for people who aren’t getting it would be useful out in the country. Early melanoma detection, for example, costs you $1000 and it’s fixed; late melanoma costs you $100,000 and it’s probably not fixed.”
Freeman adds that while face-to-face consultations are seen as the gold standard, more than half of healthcare services can be delivered without a medical professional and patient being in the same room. “Technology can also make a real difference to the experience of ageing,” he says. “A little dongle that speaks to an iPad that functions as not only an emergency call button but also means you can talk to a doctor online, discuss wound care with the nurse and input your home-monitoring results about your diabetes – that sort of technology is definitely coming, if it’s not here already.”
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A problem with funding
The Australian Government made a significant move toward telehealth in July 2011 when it introduced Medicare rebates for online consultations across a range of medical specialties, as well as a A$6000 incentive for doctors. The incentives have now been cut back, and many doctors don’t seem inclined to expand telehealth without extra payment.
Dr Mike Civil, a Western Australian-based GP and chair of the Royal Australian College of General Practitioners’ Telehealth Standards Taskforce, says the incentives encouraged him to give telehealth a go, but they didn’t make it a no-brainer.
“We did it with Skype and our patients loved it,” he says, “but if you’re going to devote half a morning to telehealth consultations, you need to be reimbursed to make it worth your while.”
Australian Medical Association (AMA) vice-president Dr Tony Bartone raises other issues. He says that while there’s an important place for telehealth – “it adds to the suite of options that doctors have when providing care” – there are occasions and conditions where it does not suffice and a patient needs to be examined by a GP.
“You can miss things that even the highest resolution screen won’t show,” says Bartone. “That’s a reason why first consultations should ideally be done face to face, unless there is an access issue.”
On this last point, Bartone notes that “telehealth is a very good option for established doctor-patient relationships, but that presupposes the provision of adequate bandwidth. Some of us live in areas that just don’t have this.”
Time for a change?
While researchers generally agree that the traditional model of care is difficult to change, University of Queensland economist Paul Frijters has suggested another possibility for disrupting the model. He believes that telehealth could let consumers in high-income nations bypass the normal system in favour of a quick, cheap consultation from low-cost doctors in countries like India.
In a system that has resisted change for so long, it seems there is still some way to go before large-scale change will come.
Finger on the online pulse
In the absence of effective government telehealth infrastructure, technology companies are stepping in. Telstra launched its telehealth service, ReadyCare, in July 2015. Brisbane-based digital start-up ResApp, which was relisted on the Australian Securities Exchange in 2015, has developed an app that can diagnose a range of respiratory problems, including pneumonia, bronchitis and pulmonary disease, when users cough into their smartphone. Meanwhile, health fund HCF recently bought a 15 per cent stake in GP2U, joining Sonic Healthcare, which owns 12.5 per cent of the company.
When Dr James Freeman launched GP2U in 2011, it was Australia’s first dedicated online medical practice. Today, it has more than 2000 registered patients, about 1000 GPs and 300 specialists. Its service also allows messages to be sent directly to certain pharmacies about a patient’s medication, once the doctor has completed a consultation and approved a prescription. Specialist referrals by GPs for patients in eligible areas are free, but GPs set their own fees, and Freeman says they are similar to regular out-of-pocket costs – from A$49 to A$70 for 15 to 20 minutes.
Freeman is also working on a skin cancer diagnostic project, which involves a device that attaches to your smartphone and provides “a medical-grade” image of your skin, just as you would receive in a skin cancer clinic. A computer algorithm then analyses the results. Says Freeman: “That’s a pretty interesting little project.”
Telehealth in China
The number of people in China aged over 60 represents 15.5 per cent of the country’s population and is projected to reach 24 per cent – or 302 million people – by 2050.
Benjamin Shobert, founder and managing director of Rubicon Strategy Group, a US-based consulting firm that specialises in market analyses of China’s health and senior care industries, says this presents both challenges and opportunities for the country’s health sector.
“The nature of China’s healthcare system is such that if there’s one way it’s going to leapfrog the developed West, it will probably be something to do with telehealth,” he says.
Shobert says there are three distinct telehealth markets in China. The first is government-sponsored telehealth, designed to provide rural areas with access and expertise. The second is designed specifically to augment community care and health infrastructure by providing an alternative to in-person health consultations. The third telehealth market is driven by high net worth individuals and families who want to access a second opinion from a Western physician.
Shobert points to an ecosystem developing in China where online platforms store health data and enable consumers to schedule, pay for and receive a consultation, plus order pharmaceuticals.
“There are various pilots across the country,” he adds. “I think everybody who’s in this space can see a way in which all this can come together and create a very efficient, a very interesting and a very unique health system with telehealth as its foundation.”
Shobert says patients in China are accustomed to brief, impersonal interactions with their physician, so “telehealth is a much more intuitive translation of expectations than what we would see in the West”.
While telehealth technology remains fairly common, Shobert says the commercial models in China are proving to be innovative. “Companies like China Primary Care are going to big state enterprises and saying that they’ll help them manage their healthcare costs if they’ll let them sell a telehealth service to their employees as part of their benefit plan,” he says.
Regulations around telehealth in China remain in flux, but Shobert says they are moving in favour of innovation. “Telehealth struggles with ... wide disparities in how policies are interpreted and implemented locally,” he notes. “Overall, if you’re an investor or an operator in at least the first two types of telehealth in China, the regulatory environment is not your problem.”
Shobert believes it’s likely that China will view telehealth as a meaningful alternative to community care clinics. “It’s going to be very interesting to watch,” he says.
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