Paper presented at TeleMed 98, the sixth International Conference on Telemedicine and Telecare, Royal Society of Medicine, London, UK, 25-26 November 1998
John Mitchell & Associates, Sydney, New South Wales
This paper examines the uneven diffusion of telemedicine services in Australia over the last four years and cites both the barriers to and drivers behind the future expansion of telemedicine.
Telemedicine services in Australia were the focus of a national study conducted by the author in late 1997 and early 1998 for the Australian Commonwealth Government’s Department of Industry, Science and Tourism (DIST), culminating in the report: “From fragmentation to integration: the telemedicine industry in Australia” (July 1998). The report concluded that despite the establishment of some isolated, and world class, telemedicine networks, telemedicine in Australia remains fragmented and uncoordinated. If it is to live up to its potential and be diffused throughout the health sector, it must become integrated effectively with mainstream health care. Such integration would require active participation by all parties, including Government, business and consumers.
In relation to the number of telemedicine installations overseas, Togno, Ash and Mitchell (1996) claim that, on a per-capita basis, Australia is one of the world leaders in telemedicine. They noted that geographical challenges in Australia are both a stimulus and a barrier to the spread of telemedicine. While Australia lacks many of the sophisticated aspects of the telemedicine industry in, say, the USA, such as professional and industry associations, journals, research bodies and technology expositions, Australia’s pace in installing new sites is in advance of the average world rate. However, the diffusion of telemedicine is uneven, with some medical applications, such as teleradiology, far outreaching other applications. The reasons for this unevenness, the barriers to telemedicine and the drivers for expansion will be discussed in this article.
The methodology for the DIST study of telemedicine in Australia (Mitchell, 1998) included the use of emailed survey forms, face to face interviews, telephone interviews, web searches and a literature search of telemedicine publications. 248 personnel were interviewed or returned the 21-point survey form. The survey form and the 33,000 word report are available on the DIST web site. International trends were used as benchmarks by the author and were observed by participation in international conferences in Kuala Lumpur and in California in late 1997.
There is no established definition of telemedicine in Australia, and it is becoming increasingly difficult to define its boundaries, particularly in areas that involve fast-changing information and communications technologies. Other factors that are blurring the boundaries include globalisation and deregulation. Essentially, from a business standpoint, the telemedicine industry can be defined loosely by the types of technologies used; the markets; and the stakeholders (e.g. customers, vendors, suppliers, users). For the DIST study, telemedicine was defined as consisting of the following components: the delivery of health services (including clinical, educational and administrative services), at a distance, through the transfer of information, including audio, video and graphic data, using telecommunications and involving a range of health professionals, patients and other recipients.
The study revealed a number of trends: teleradiology and telepathology are becoming increasingly embedded in practice; telepsychiatry dominates the videoconferencing-based applications; innovative medical education services are commonly delivered across State borders; and clinical, fee-paying telemedicine services are almost non-existent. The study shows that evaluation of telemedicine activities and research in the field is at an early stage.
Telemedicine activities started to gain attention in Australia in 1994. One of the key early drivers was the then-Commonwealth Government body, Health Communication Network, which funded a number of innovative projects, particularly the teleradiology network linking rural NSW towns with St Vincent’s in Sydney, and the telepsychiatry network of the South Australian Mental Health Service, linking Glenside Hospital in Adelaide with a number of country hospitals. Several other telemedicine projects that commenced at that time have continued to make an impact on the field in Australia. The Renal Telemedicine Network of The Queen Elizabeth Hospital in South Australia, which is a national benchmark for telemedicine evaluation studies (Health On Line, p. 49), commenced operation in September 1994. The first of the Victorian telepsychiatry links also began in this period, resulting in over 36 installations by 1998.
A major driver behind these early projects included the desire to provide equity and access to rural populations. Because of the lack of psychiatrists outside of capital cities, psychiatry was an understandable early adopter of telemedicine technology in Australia. Other drivers behind these initial projects were an interest in using technology to save on travel and other costs and an interest in providing improved quality of care.
Telemedicine projects multiplied quickly in 1995, particularly with New South Wales committing $2m to 12 separate projects, covering a range of clinical applications. The largest single addition of videoconferencing-based telemedicine sites occurred in 1996, when Queensland Health added 62 sites for clinical purposes and 30 sites for rural medical education.
By late 1998, there are around 280-300 functioning videoconferencing-based telemedicine sites in Australia, compared to approximately 30 sites in 1994. This estimate of 280 sites includes both the State-based facilities and those owned by private health practitioners and hospitals. Teleradiology sites increased in 1998, from around 150 to over 300, due to the initiative of one of the major two teleradiology vendors distributing free ‘receive’ site software to every radiologist in Australia.
Queensland has the most videoconferencing-based sites, at over 100, and Victoria and South Australia have around 50 sites each. The reasons for the high level of activity in these States include the leadership of key individuals, supportive Governments, specific service needs (e.g. telepsychiatry) and the need to overcome the problems of distance.
A detailed list of sites has been compiled and maintained by the Australian Health Ministers’ Advisory Council (AHMAC) Telemedicine Sub-Committee and includes telemedicine applications in opthalomogy, teleradiology, mental health, correctional services, pathology, oncology, obstetric ultrasound, psychiatry, paediatrics, forensic mental health, intensive care, accident and emergency, dermatology, renal dialysis, rehabilitation, Aboriginal health as well as numerous educational uses. The list is contained in an appendix to the DIST report.
Two applications have dominated telemedicine in Australia since 1994: telepsychiatry and teleradiology. The scale of teleradiology activity in Australia is difficult to quantify, for similar reasons cited by Allen (1997), particularly the fact that the information is commercially sensitive. Teleradiology pervades the radiology industry in Australia. In South Australia, for instance, all three of the major radiology companies use teleradiology to link to all of their distributed sites, including Broken Hill in New South Wales, and Alice Springs and Darwin in the Northern Territory.
The reasons for teleradiology’s pervasiveness include the reliability of the technology, the quality of the images, the speed of decision making and the ability to have a specialist in one location provide advice to generalist staff at another site. The portability of the technology now enables radiologists to take home a PC with modem and to receive images from country or metropolitan hospitals. Teleradiology technology is also reducing significantly in price and its expansion is assured.
Telepsychiatry dominates the use of videoconferencing-based telemedicine in Australia, by a very significant margin. One industry commentator estimates that telepsychiatry represents 70% of real usage of videoconferencing systems in telemedicine in Australia: (Ash, PictureTel Telemedicine Update, p.1, August,1997) Another reason for telepsychiatry’s dominance includes the point made earlier: that the vast majority of psychiatrists live in the capital cities of Australia, leaving the rural areas greatly under serviced. Research undertaken in Australia has also demonstrated that the available technology is considered suitable by most patients and clinicians.
Discussions with industry representatives reveal that the market is expected to grow considerably in the next few years, due to:
- the increasing popularity of a number of cheaper videoconferencing units, in the price bracket of AUS$10-20,000, leading to the purchase of multiple codecs for the one hospital building or for the development of application-specific networks
- the wider availability of the new European style of Integrated Services Digital Network (ISDN) through local, digital Telstra exchanges is expected to lead to many more ISDN connections to community health centres and small hospitals, in locations where ISDN was not previously available
- ISDN usage is expected to grow in proportion to the number of new videoconferencing units and because of a growing interest in the more expensive 384kbps transmission rate, compared to the lower costs for 128kbps
- desktop videoconferencing, operating over the plain old telephone service (POTS), is expected to become used more frequently for telemedicine to the home
- industry representatives expect the teleradiology market to grow by 50% in 1998.
Telemedicine can be expected to grow even more in coming years, for the following additional reasons: the possibility of telemedicine consultations becoming eligible under the Medicare Schedules Benefit, as recommended in Health On Line; private health practitioners embracing this currently public-dominated arena; and the equipment and transmission options becoming economical and more widespread.
The study identified the following emerging markets in telemedicine in Australia:
- call centres (e.g. paediatric call centre)
- telemedicine to the home
- telemedicine to aged care facilities
- correctional services telemedicine
- Aboriginal telemedicine
- Defence forces telemedicine
- ambulance telemedicine
- emergency, outback telemedicine
- combining digital communications at the GP’s desktop
- telehealth information on the Web
- export of telemedicine services to Asia.
The report shows that telemedicine in Australia is in an embryonic stage, and the barriers to its further development are substantial. At the same time, the industry is immature with a lack of associations, active research bodies, professional publications, healthy competition, and private investment. There are on the other hand some outstanding individual telemedicine networks with high levels of use that have been presented in the national and international literature (e.g. Mitchell, B. et al, 1996, Yellowlees and Kennedy, 1997).
A wide-ranging examination of the barriers to the development of telemedicine in Australia was undertaken by the House of Representatives Standing Committee, for the report Health On Line (1997). The report highlighted in particular the lack of remuneration for general practitioners as a barrier to their adoption of telemedicine. However, recent developments in the USA (Lapolla and Mills, 1997) suggest that simply providing a remuneration system for tele-consulting will not be a panacea. Health On Line (1997) was very critical of the wastage of money on many projects that did not disseminate their findings. The report also noted that medico-legal issues were a potential hazard and the question of the medical registration of health care professionals was also discussed by the Committee.
The issues related to access to telecommunications infrastructure were investigated by the Committee and the following matters were underlined: unreliable telephone and ISDN services in sections of Australia; the rollout of broadband services to only a section of suburban Australia; the high cost of satellite services. Other barriers to the extension of telemedicine investigated for Health On Line (1997) included privacy, confidentiality and the security of information.
The report, Telehealth in Rural and Remote Australia, 1997, took the view that the adoption of telehealth needs to be seen as part of a wider move to encourage rural health professionals to adopt ‘IT&T’:
Access, training and participation with regard to Telehealth need to be within a national policy and regulatory framework which will facilitate adoption of IT&T. (p.13)
The list of barriers cited by the report is very similar to that identified by Health On Line (1997). The length of the list is a further reminder that there are many rows of hurdles in front of telemedicine in Australia:
At present there are several barriers with regard to the use of IT&T:
- reimbursement for Telehealth consultations;
- legal liability;
- privacy and security;
- regulations regarding sharing of medical information;
- standards for information management;
- standards of technology;
- State, Territory and regional/district policies and practices regarding health and IT&T and funding arrangements. (p. 13)
The DIST study of telemedicine in Australia suggests that some of the major barriers to telemedicine adoption relate to the nature of the industry, including the immaturity of the industry, the limited telecommunications infrastructure, the lack of appropriate dialogue between vendors and buyers about solutions required and the lack of partnerships in the industry. Remuneration is only one barrier. There are, of course, other substantial organisational, financial and attitudinal barriers to telemedicine adoption.
While there is encouragement for a national coordinating organisation in telemedicine in Australia, there is little agreement about whether it be focused on technology matters, such as the availability of infrastructure or standards, or on strategic planning, policy development, promotion, evaluation, marketing or other issues. There is a place for the Australian Government to provide infrastructure, reduce obstacles, facilitate investment and build wealth through research and development in telemedicine. There seems to be a consensus regarding the need for the Government to assume a leadership role in regulation to ensure a consistent approach across Government portfolios, providing forums for dialogue and laying off government intellectual property rights to the private sector willing to assume commercialisation risks. The interviewees for the DIST study accepted that industry needed to provide leadership by nurturing consumer confidence and comfort with new systems and providing self-regulation by developing collaborative relationships with consumers.
Further development of telemedicine in Australia will require detailed assessment of the following:
- Major environmental trends that may influence the development of telemedicine
- Telemedicine’s internal strengths and weaknesses
- External opportunities and threats
- Barriers to entering the market
- Needs of various segments of the market
- Infrastructure requirements
- Quality of system integration
- User motivation and barriers to adoption
- Value-added aspects of products and services.
The evidence provided through our DIST report suggests that the telemedicine community in Australia is not debating these sorts of issues in any depth. Public discussion of these and other related issues now needs to occur through appropriate forums, associations and groups.
Allen, A, ed. Telemedicine Today. October 1997; 5
Bashshur, Rashid L. ‘Perspective: On the Definition and Evaluation of Telemedicine’. Telemedicine Journal. 1995; 1: 21-22
House of Representatives Standing Committee on Family and Community Affairs. Health On Line. A Report on Health Information Management and Telemedicine. Australian Government Publishing Service, 1997
Lapolla M, Millis B. Is telemedicine reimbursement a real barrier or a convenient straw man?, Telemedicine Today. December 1997; 5
McKinnon, M. Information technology in medicine. Medical Journal of Australia. Dec 1/15 1997; 574
Mitchell B, Mitchell J, Disney APS. User adoption issues in renal telemedicine. Journal of Telemedicine and Telecare. 1996; 2: 81-86
Mitchell, J and Disney, A.P.S. Clinical Applications of Renal Telemedicine. Journal of Telemedicine and Telecare. 1997; 3: 158-162
Mitchell J, Mitchell B. Establishing Renal Clinical Telemedicine. Report TQEH Renal Network. 1995
Mitchell J. Telemedicine Industry in Australia: Case Study of Existing and Emerging Opportunities. Telemedicine Journal. 1998; 4: 187-191
Mitchell, J. 1998, From Fragmentation to Integration: the Telemedicine Industry in Australia, the Department of Industry, Science and Tourism, Canberra
Yellowlees P, Kennedy C. Telemedicine: here to stay. Medical Journal of Australia. 1997; 166: 262-5
Yellowlees P. State of Telemedicine Technology, Trials, Projects and Experiences. Paper presented at TeleMed Asia 97, September 1997