Specialist paediatric health services for patients in remote - - PDF document

Specialist paediatric health services for patients in remote locations: the role of telemedicine in Australia

Dr Anthony Smith, Associate Professor Deputy Director

Centre for Online Health

• Prof Shuji Shimizu
• Yoko Noda
• Kyushu Hospital University
• Sponsors
• Centre for Online Health, UQ

Acknowledgements

• Centre for Online Health (COH)
• Australia in context
• Paediatric telemedicine services ‐ logistics
• Recent developments – Government funding
• Future trends

Mud‐map (Overview)

• Broad interest and experience in telehealth
• Queensland Telepaediatric Service >12y
• Adult/geriatric telehealth services
• SFT Conference
• www.uq.edu.au/coh

Centre for Online Health

 New models  Evaluation  Service delivery  Teaching

Texas Great Britain Ireland Japan Germany New Zealand

Background

  Queensland

Queensland -

• second largest state, pop ~ 4.2 m

second largest state, pop ~ 4.2 m

  60% population

60% population – – SE corner SE corner

  20% major coastal towns

20% major coastal towns

  15% remote (650,000)

15% remote (650,000)

  Indigenous

Indigenous – – 520,000 520,000

  Qld

Qld – – 150,000 150,000

Any medical activity involving distance

• can be done in two ways
• real‐time (e.g. videoconferencing)
• pre‐recorded (e.g. email)

Telemedicine

Why do telemedicine?

• There may be no alternative
• Telemedicine may be better than existing conventional

services

Telemedicine

Key issues

• Extensive distances and location of specialist health services
• Equity of access to health services for regional and remote

population

• Large videoconference networks – but relatively slow uptake

Telehealth coordination

• INCENTIVE
• Single point of contact
• Manages referral
• Liaises with specialists
• Scheduled appointment
• Facilitates medical records
• Manages videoconference session
• Collects activity data
• Organises follow‐up if required

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

Telepaediatrics in Queensland

Other 18% Dermatology 2% Ophthalmology 2% Cardiology 2% Orthopaedics 2% Nephrology 3% Oncology 3% Endocrinology 5% General Paediatrics 5% ENT 7% Neurology 10% Burns 14% Child Psychiatry 27%

(n = 11,250 consultations)

Telepaediatrics in Queensland

400 800 1200 1600 2000 2400 2800 2000 2002 2004 2006 2008 2010

• 13,650 consultations over 12 years
• 2400 consultations per y

Telepaediatrics in Queensland

Consultations

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

• 2 years – 152 consultations (97 pts)
• Retrospective audit of medical notes
• Diagnosis – 99%
• Management – 93%

Telepaediatrics ‐ ENT

~90% significant disease/deafness rate Long‐term impact:

• 1‐3y; severe disease burden (discomfort)
• 4‐5y; slow language
• 5‐7y; slow learning
• 10‐11y; behaviour problems, truancy
• 15y; illiteracy, substance abuse

Indigenous health screening

• Community health services
• Visiting specialists
• ENT
• Dental
• Dermatology
• Ophthalmology
• Psychiatry
• Respiratory

Outreach – physical travel to remote sites

Indigenous health screening

• Indigenous health workers
• Specialist outreach services and telehealth support
• ENT
• Dental
• Dermatology
• Ophthalmology
• Psychiatry
• Respiratory

Indigenous health screening

• To provide routine health screening for all Indigenous children

in Cherbourg and surrounding communities

• To 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 screening

• Pre: 380 / 980 = 39% (average rate per annum)
• Post: 83% (first 12 months)

Telepaediatrics – Indigenous Health

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

Smith AC, Kimble R, Bailey D, Mill J, and Wootton R. Diagnostic accuracy of and patient satisfaction with telemedicine for the follow-up of paediatric burns patients. Journal of Telemedicine and Telecare 2004, 10(4):193-198

• Compare FTF to VC assessments
• 12 months – 25 patients
• 1.One observer, alternating process FTF/VC ‐ VC/FTF
• 2. Two observers, FTF consults

Telepaediatrics ‐ Burns

CRICOS Provider No 00025B

FTF FTF / VC

Consultant A Consultant B Concordance % n=25 Concordance % n=25 Appearance 68 60 Scar thickening 60 64 Contractures 92 92 Range of motion 92 92 Activity level 100 100 Breakdowns 96 96 Decision making 100 100

Smith AC, Kimble R, Bailey D, Mill J, and Wootton R. Diagnostic accuracy of and patient satisfaction with telemedicine for the follow-up of paediatric burns patients. Journal of Telemedicine and Telecare 2004, 10(4):193-198

Telepaediatrics ‐ Burns

300 600 900 1200 1500 1800 2100 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

FTF appointments Telepaediatrics

• 17% of all burns outpatients

Consultations

Telepaediatrics ‐ Burns

• Rapidly expanding
• Routine clinics with all paediatric surgeons
• 6 clinics per month, up to 2 hours each
• multi‐site appointments
• Pre‐admission, reviews and education
• Referrals:
• Direct to QTS via 1800 number
• Patients triaged at the RCH OPD according to postcode
• Appointments held at nearest regional hospital

Telepaediatrics ‐ Surgery

• Video links to families at home
• Palliative care, oncology
• Support from medical, nursing and allied health staff
• Logitech video – via broadband connection
• Laptops and PCs ‐ flexible

Telepaediatrics – Home support

• Telepaediatric robots
• Commenced 2004
• mobile, wireless videoconference systems
• child‐friendly
• direct to bedside

Telepaediatrics – Robots

• 2005 – Gladstone Hospital, no paediatrician
• daily ward rounds
• sub‐specialist 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

Telepaediatrics – Robots

Eliza – Mt Isa Emma - Emerald ROY – Gladstone Gypsie – Gympie Tiny Tom - Townsville

CRICOS Provider No 00025B

Neonatal ward rounds

Round led by neonatologist Family members may participate Usually informal educational opportunities Often full care team attend

• Medical
• Nursing
• Allied Health
• Social work

Mackay Base Hospital ICN, Townsville Hospital

• Child and adolescent psychiatry services
• e-CYMHS
• 30 month period
• Costs of providing telepaediatrics - video
• Costs of providing outreach – visiting psychiatrist
• Potential costs if patients travel to the RCH

Smith AC, Stathis S, Randell A, Best D, Ryan V, Bergwever E, Keegan F, Fraser E, Scuffham P and Wootton R. A cost-minimisation analysis of a telepaediatric mental health service for patients in rural and remote Queensland. Journal of Telemedicine and Telecare, 2007, 13 (Suppl. 3): 79-83

Cost minimisation analysis

Smith AC, Stathis S, Randell A, Best D, Ryan V, Bergwever E, Keegan F, Fraser E, Scuffham P and Wootton R. A cost-minimisation analysis of a telepaediatric mental health service for patients in rural and remote Queensland. Journal of Telemedicine and Telecare, 2007, 13 (Suppl. 3): 79-83

Method

FTF – Patient travel ($) FTF Outreach – Visiting Psychiatrist ($) Telemedicine – Patient seen via videoconference ($)

Total cost

514,094 299,913 230,753

Average

1073.25 494.91 380.78

Marginal

1073.25 494.91 190.01

30 months – 606 consultations

Telepsychiatry

400,000 800,000

100 200 300 400 500 600 700

Number of consultations Cost ($)

Telemedicine

Actual

Visiting Psychiatrist Patient travel

Telepsychiatry (30 months)

• Medicare items for online consultations recently

introduced in July 2011

• General practice
• Broad range of health specialties
• Focus on video consultations
• $620m+ invested by Commonwealth Government
• Financial incentives – 1st consultation, loadings
• Funding for training, support
• Promising sign for telehealth in Australia...

Developments in Australia

• New MBS telehealth items ‐ what is the prognosis?
• Likely uptake, long‐term trends?
• Learn from experience (successes and failures)
• Telepsychiatry in Australia
• Commonly reported, telehealth friendly
• MBS items for telepsychiatry ‐ introduced early 2003

Telehealth uptake

• Mental health in Australia
• 1/3 population (7 million) live outside major cities
• Rural and remote population:
• Higher prevalence of chronic health conditions
• 16% more likely to report mental problems
• Prevalence of mental health conditions is about 12%
• Approx. 800k people…
• Telemedicine potential!

Background

• Review of MBS activity for psychiatry services
• Reports via Medicare Australia*
• July 2002 – June 2011
• FTF and VC items compared
• Exclusions
• Services by hospital doctors to public patients in public

hospitals

• Department of Veteran Affairs (DVA) funded services

Methods

* http://www.medicareaustralia.gov.au/statistics/mbs_item.shtml

• Review of MBS activity* for psychiatry services
• Activity reports included:
• Services delivered – number of consultations
• Benefits paid – Medicare costs

Methods

* http://www.medicareaustralia.gov.au/statistics/mbs_item.shtml

• MBS items (for VC) introduced in 2003

Telepsychiatry MBS items

Consult time FTF VC <15 min 300 353 >15 min and < 30 min 302 355 >30 min and < 45 min 304 356 >45 min and < 75 min 306 357 >75 min 308 358

Ref: http://www.medicareaustralia.gov.au/statistics/mbs_item.shtml

• Registered services (July 2002 – June 2011)

Telepsychiatry MBS items

Consult time FTF VC <15 min 300

371,501

353

1644

>15 min and < 30 min 302

2,372,696

355

2710

>30 min and < 45 min 304

4,319,122

356

1623

>45 min and < 75 min 306

6,389,628

357

1966

>75 min 308

358,386

358

60

Total

13,811,333 8003

Ref: http://www.medicareaustralia.gov.au/statistics/mbs_item.shtml

• Benefits paid (July 2002 – June 2011)

Telepsychiatry MBS items

Consult time FTF VC <15 min 300

$12,501,152

353

$73,611

>15 min and < 30 min 302

$158,144,708

355

$246,630

>30 min and < 45 min 304

$440,522,059

356

$221,258

>45 min and < 75 min 306

$941,480,922

357

$380,118

>75 min 308

$59,479,219

358

$12,873

Total

$1,612,128,061 $934,489

Ref: http://www.medicareaustralia.gov.au/statistics/mbs_item.shtml

• Benefits paid (July 2002 – June 2011)

Results

• Benefits paid (July 2002 – June 2011)

Results

• Benefits paid (July 2002 – June 2011)

Results Summary

• MBS Activity (July 2002 – June 2011)
• 14 million services (psychiatry consultations)
• $1.6 billion MBS funded psychiatry services

FTF VC % Services 13,811,333 8003 0.6 Benefits $1,612,128,061 $934,489 0.06

Findings

• Despite item numbers being available for

telepsychiatry since 2003, uptake has been very slow

• Considering reported telehealth success in psychiatry

– results may be surprising?

• Telehealth success factors
• Funding
• Clinical services (clinicians)
• Infrastructure, equip and telecommunications
• Administrative and clinical systems

Critical factors

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

• Careful design – clinical requirements
• Organisational support – willingness to change
• Re‐engineering conventional referral processes
• Complementary (with outreach, patient travel)
• Incentives – must be comparable (or better than FTF)
• Clinician support (near and far)
• Perseverance

Telehealth ingredients

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

• MBS psychiatric services (July 2002 – June 2011)

Potential

Number of services (VC)

<3000 consultations per y

• Develop new services systematically
• Start small and gradually develop
• New applications:
• Feasibility, technical, user satisfaction
• Clinical efficacy – comparable to FTF
• Economic evaluation – patient, health service, society
• Learn from experience – successes and failures

Practical tips

• MBS funding for telehealth is welcomed in Australia
• Based on telepsychiatry experience, realistically ‐ the

uptake of MBS telehealth items is likely to take time

• A whole of system approach is essential for the

successful integration of telehealth

Conclusions

• Model used for telepaediatrics in Queensland is likely

to be useful for other states and countries

• Service delivery models should include a combination
• f telehealth, outreach, local and tertiary services
• Opportunities to strengthen clinical networks and

deliver high quality specialist services in the most efficient manner

Conclusions

Dr Anthony Smith Associate Professor Deputy Director Centre for Online Health Email: asmith@uq.edu.au Web: www.uq.edu.au/coh

Dōmo arigatō