Emerging Health Applications and Emerging Health Applications and Mobile Delivery

TELEPAEDIATRICSTELEPAEDIATRICS

Associate Professor Anthony Smith

Centre for Online Health

eHealth @ CeBITJune 1 2011 - Sydney, Australia

Centre for Online HealthUQ research centre closely linked with the RCHUQ research centre closely linked with the RCH

Ce t e o O e ea tUQ research centre closely linked with the RCHUQ research centre closely linked with the RCHresearch activities combined with service deliveryresearch activities combined with service deliveryt l di i t l h ltht l di i t l h lthtelemedicine, telehealth…telemedicine, telehealth…teaching teaching –– eHealthcare courses, SFT ConferenceeHealthcare courses, SFT Conferencefocus is on clinical workfocus is on clinical work

telepaediatricstelepaediatricspptelegeriatricstelegeriatrics

Why telehealth?y te e ea t

Inequality of access to health careInequality of access to health careSSpecialistpecialist services typically in metro areasservices typically in metro areasDistributed populationDistributed populationLarge distances and travel timeLarge distances and travel time

++llogisticsogisticsggcostscostsstressstressiinconveniencenconvenience

Where is the incentive? e e s t e ce t e

It It is is more convenient to transfer a patient more convenient to transfer a patient through the conventional system than to arrange through the conventional system than to arrange a telehealth consultationa telehealth consultationa telehealth consultation a telehealth consultation

O f h f i d f ff iO f h f i d f ff iOne of the factors required for an effective One of the factors required for an effective telehealth service is a single point of contact telehealth service is a single point of contact --telehealth coordinationtelehealth coordinationtelehealth coordinationtelehealth coordination

Smith AC, Isles A, McCrossin R, Van der Westhuyzen J, Williams M, Woollett H and Wootton R. The point of referral barrier - a factor in the success of telehealth, Journal of Telemedicine and Telecare 2001; 7 (Suppl.2): 75-78

Telepaediatric Servicee epaed at c Se ce

Commenced in November 2000Commenced in November 2000Central referral centre with 1800 direct phoneCentral referral centre with 1800 direct phoneCentral referral centre with 1800 direct phone Central referral centre with 1800 direct phone number:number:

RCHRCHRCHRCHMater ChildrenMater Children’’s Hospitals Hospital

Clinical support service Clinical support service –– not technology drivennot technology drivenLargest reported service of its kind in AustraliaLargest reported service of its kind in Australia

Smith AC, Isles A, McCrossin R, Van der Westhuyzen J, Williams M, Woollett H and Wootton R. The point of referral barrier - a factor in the success of telehealth, Journal of Telemedicine and Telecare 2001; 7 (Suppl.2): 75-78

Telepaediatric Servicee epaed at c Se ceG lGeneral

paediatrics

S bSub-Specialist referrals

Home telehealth

Telepaediatrics

Critical careIndigenous

health screening

Neonatal intensive

care

Telepaediatric Activity (10y)Neurology

10%(n = 11,250 consultations)

e epaed at c ct ty ( 0y)

ENT7%

Burns14%

General Paediatrics5%

7%

Endocrinology5%

Orthopaedics

Nephrology3%

Oncology3%

Child Psychiatry27%

O hth l l

Cardiology2%

Orthopaedics2%

Other18% Dermatology

2%

Ophthalmology2%

Telepaediatric Activitye epaed at c ct ty11 250 consultations over 10 years11 250 consultations over 10 years11,250 consultations over 10 years11,250 consultations over 10 years2400 consultations per y2400 consultations per y

2400

2800

2000

2400

1200

1600

400

800

02000 2002 2004 2006 2008 2010

Post-acute burnsost acute bu s

17% of all burns outpatients17% of all burns outpatients

FTF appointments Telepaediatrics

17% of all burns outpatients17% of all burns outpatients

1800

2100pp p

1200

1500

atio

ns

900

1200

Con

sulta

300

600

02001 2002 2003 2004 2005 2006 2007 2008 2009 2010

ENT pre-screening clinics

2 years2 years –– 152 consultations (97 pts)152 consultations (97 pts)2 years 2 years 152 consultations (97 pts)152 consultations (97 pts)Retrospective audit of medical notesRetrospective audit of medical notesDiagnosis Diagnosis –– 99%99%Management Management –– 93%93%

Smith AC, Dowthwaite S, Agnew J and Wootton R. Concordance between real-time telemedicine assessments and face-to-face consultations in paediatric otolaryngology. The Medical Journal of Australia. 2008, 188 (8): 457-460

Indigenous healthd ge ous ea t

Middle Middle ear infections are very ear infections are very commoncommon

LongLong--term impact:term impact:

11--3y; severe disease burden (discomfort)3y; severe disease burden (discomfort)44--5y; slow language5y; slow languagey; g gy; g g55--7y; slow learning7y; slow learning1010--11y; behaviour problems, truancy11y; behaviour problems, truancy15y; 15y; illiteracy, substance illiteracy, substance abuseabuse

Indigenous health screeningd ge ous ea t sc ee g

Community health servicesCommunity health servicesVisiting specialistsVisiting specialistsg pg p

ENTENTDentalDentalDermatologyDermatologyOphthalmologyOphthalmology

Outreach –physical travel OphthalmologyOphthalmology

PsychiatryPsychiatryRespiratoryRespiratory

to remote sites

Indigenous health screeningd ge ous ea t sc ee g

Indigenous health workersIndigenous health workersSpecialist Specialist outreach services and telehealth supportoutreach services and telehealth supportpp pppp

ENTENTDentalDentalDermatologyDermatologyOphthalmologyOphthalmologyOphthalmologyOphthalmologyPsychiatryPsychiatryRespiratoryRespiratory

Indigenous health screeningd ge ous ea t sc ee g

To provide routine health screening for all Indigenous children in Cherbourg and surrounding communitiessurrounding communities

To develop a service which can be managedTo develop a service which can be managed locally by dedicated Indigenous health workers.

To improve screening rates – above 90%

To ensure early detection (assessment) and treatment of chronic diseases.

Indigenous health screeningd ge ous ea t sc ee g

= Telepaediatric health screening unit

C = Telepaediatric health screening clinic

= Specialist siteS

D = Database

BiloelaMoura

Woorabinda

C

DS

Mundubbera

Kingaroy

Theodore

Gayndah MurgonCherbourg

Indigenous health screeningd ge ous ea t sc ee gPre: 380 / 980 = 39% (average rate per annum)Pre: 380 / 980 = 39% (average rate per annum)Pre: 380 / 980 = 39% (average rate per annum)Pre: 380 / 980 = 39% (average rate per annum)Post: 83% (first 12 months)Post: 83% (first 12 months)

100

Overall screening rate % (n=980)

70

80

90

100

40

50

60

10

20

30

02006 2007 2008 2009 2010

Indigenous health screeningd ge ous ea t sc ee gResults (February 2009Results (February 2009 –– June 2010)June 2010)Results (February 2009 Results (February 2009 –– June 2010)June 2010)

Cherbourg region only All Casesg g yTests Pass Fail Tests Pass Fail

Ear 301 113 188 1046 699 347physical (62%) (33%)Hearing 215 172 43

(20%)884 807 77

(9%)( ) ( )

Vision 151 127 24 (16%)

721 638 83(12%)(16%) (12%)

Anaemia 109 75 34 (31%)

628 521 107(17%)

Elliott G, Smith AC, Bensink ME, Brown CA, Perry C, Stewart C and Scuffham P. The Feasibility of a Community-Based Mobile Telehealth Screening Service for Aboriginal and Torres Strait Islander Children in Australia. Telemedicine and eHealth Journal, 2010, 16 (9): 950-956

Telepaediatric robotsp

Smith AC, Coulthard M, Clark R, Armfield N, Taylor S, Goffe R, Mottarelly I, Youngberry K, Isles A and Wootton R. Wireless telemedicine for the delivery of specialist paediatric services to the bedside. Journal of Telemedicine and Telecare 2005, 11 (Suppl. 2): 81-5

Telepaediatric robotsLogistics:Logistics:

pLogistics:Logistics:

All referrals centrally managed through the COHAll referrals centrally managed through the COHSystems operated over VPN ISDN or DSLSystems operated over VPN ISDN or DSLSystems operated over VPN, ISDN or DSLSystems operated over VPN, ISDN or DSLRemote management of systemsRemote management of systems

ffRoutine testing of systems and email alertsRoutine testing of systems and email alerts

Telepaediatric robots20052005 –– Gladstone Hospital, no paediatricianGladstone Hospital, no paediatrician

p2005 2005 Gladstone Hospital, no paediatricianGladstone Hospital, no paediatrician

daily ward roundsdaily ward roundssubsub specialist consultationsspecialist consultationssubsub--specialist consultationsspecialist consultations

Smith AC, Coulthard M, Clark R, Armfield N, Taylor S, Goffe R, Mottarelly I, Youngberry K, Isles A and Wootton R. Wireless telemedicine for the delivery of specialist paediatric services to the bedside. Journal of Telemedicine and Telecare 2005, 11 (Suppl. 2): 81-5

Telepaediatric robots20062006 -- 2008 funding to expand robot network2008 funding to expand robot network

p2006 2006 2008 funding to expand robot network2008 funding to expand robot network

four new systemsfour new systemspaediatric support and educationpaediatric support and educationpaediatric support and educationpaediatric support and education

Smith AC, Coulthard M, Clark R, Armfield N, Taylor S, Goffe R, Mottarelly I, Youngberry K, Isles A and Wootton R. Wireless telemedicine for the delivery of specialist paediatric services to the bedside. Journal of Telemedicine and Telecare 2005, 11 (Suppl. 2): 81-5

Eliza – Mt Isa

ROY – Gladstone

Tiny Tom -Townsville

Emma - EmeraldGypsie – Gympie

Telepaediatric robotspNeonatal cases referred from Neonatal cases referred from Mackay to Townsville Mackay to Townsville –– about about 350 350 km apart km apart

Limited communication Limited communication during admission, discharge during admission, discharge planning difficultplanning difficult

Mackay

Weekly ward rounds with Weekly ward rounds with both sites the patient andboth sites the patient and

Tiny Tom – Townsville

both sites, the patient and both sites, the patient and familyfamily

Family costs Travel time FTF (n=200)

a y costs• Average per family

(min)

Di t

( )

VC (n=200)

Distancetravelled (km)

Direct costs(A$)

Time off work(min)

0 50 100 150 200 250

Smith AC, Youngberry K, Isles A, Mc Crossin R, Christie F and Wootton R. The family costs of attending hospital outpatient appointments via videoconference and in person, Journal of Telemedicine and Telecare 2003; 9 (Suppl. 2): 58-61

Health department

QueenslandQueensland HealthHealth

ea t depa t e t

Queensland Queensland HealthHealthPatient travel subsidy $Patient travel subsidy $4545M+ M+ per yper ypotential potential for significant savingsfor significant savings

Smith AC, Scuffham P and Wootton R. The costs and potential savings of a novel telepaediatric service in Queensland. BMC Health Services Research 2007, 7:35, available online at http://www.biomedcentral.com/1472-6963/7/35

Key lessons

T l di i h l i t h lthT l di i h l i t h lth

ey esso s

Telemedicine can help improve access to health care Telemedicine can help improve access to health care for people in rural and remote communities, but its for people in rural and remote communities, but its uptake has been slow and fragmented.uptake has been slow and fragmented.uptake has been slow and fragmented.uptake has been slow and fragmented.

For telemedicine to become a mainstream For telemedicine to become a mainstream service, its focus must move beyond service, its focus must move beyond simply the provision of equipment and simply the provision of equipment and network connectivitynetwork connectivitynetwork connectivity.network connectivity.

The success of telemedicine depends onThe success of telemedicine depends onThe success of telemedicine depends on The success of telemedicine depends on administrative and clinical systems that administrative and clinical systems that support its operation.support its operation.

Smith AC and Gray LC. Telemedicine across the ages. The Medical Journal of Australia. 2009, 190 (1): 15-19

Critical factorsC t ca acto s

Clinical servicesClinical servicesInfrastructure equip and telecommunicationsInfrastructure equip and telecommunicationsInfrastructure, equip and telecommunicationsInfrastructure, equip and telecommunicationsAdministrative and clinical systemsAdministrative and clinical systems

Developments...e e op e ts

National Broadband Network (NBN)National Broadband Network (NBN)

Potential for telemedicine...Potential for telemedicine...

Improved access and affordabilityImproved access and affordabilityGreater reliabilityGreater reliabilityGreater reliabilityGreater reliabilityPrimary care applicationsPrimary care applications

Developments...e e op e ts

Medicare (MBS) reimbursements for videoMedicare (MBS) reimbursements for video--consultations commence in July 2011consultations commence in July 2011

IIterativeterative implementation recommended:implementation recommended:security, privacy and authenticationsecurity, privacy and authenticationhhardwareardware and softwareand softwareInteroperability and integrationInteroperability and integrationcchangehange managementmanagement

Gray LC, Smith AC, Armfield NR, Travers C, Croll P, Caffery LJ. Assessment of Telehealth Implementations and Associated Requirements. Dept. of Health and Ageing, May 2011

Change managementC a ge a age e t

Telehealth implies a change in practiceTelehealth implies a change in practiceRRee--thinking how services are delivered (FTF, VC)thinking how services are delivered (FTF, VC)This may take considerable time and the results This may take considerable time and the results are unpredictableare unpredictableNNeeds organisational support for success eeds organisational support for success ––across a wide range of settingsacross a wide range of settings

Gray LC, Smith AC, Armfield NR, Travers C, Croll P, Caffery LJ. Assessment of Telehealth Implementations and Associated Requirements. Dept. of Health and Ageing, May 2011

ConclusionsCo c us o s

Centralised telehealth coordination model is Centralised telehealth coordination model is effectiveeffective aand sustainablend sustainableeffective effective aand sustainable.nd sustainable.

Service delivery models should include aService delivery models should include aService delivery models should include a Service delivery models should include a combination of telehealth, outreach, local and combination of telehealth, outreach, local and tertiary servicestertiary servicestertiary services tertiary services

Practical tips…act ca t ps

Develop new telehealth services systematicallyDevelop new telehealth services systematicallyStart small and gradually expandStart small and gradually expandg y pg y p

New applications:New applications:New applications:New applications:Feasibility, technical, user satisfactionFeasibility, technical, user satisfactionClinical efficacy Clinical efficacy –– comparable to FTFcomparable to FTFyy ppEconomic evaluation Economic evaluation –– patient, health service, societypatient, health service, society

Learn from experience Learn from experience –– successes and failuressuccesses and failures

SFT 11SFT-11• December 1st 2nd 2011; Brisbane• December 1st -2nd, 2011; Brisbane• 2nd Annual General Meeting – ATHS• Abstracts close 25th July 2011

www.sftconference.com.au• Australasian TeleHealth Society

www aths org auwww.aths.org.au

Dr Anthony Smith

Deputy Director, Associate ProfessorCentre for Online Health

Email: asmith@uq.edu.auWeb: www.uq.edu.au/cohq