So work at the Centre of online help in the Centre of Queensland and I have a number of other positions and academic responsibilities, one being in the CRE of Telehealth, which has recently been established in Australia and, more recently, a role in Denmark as well. I visit Denmark every year and I'm beginning to take on some PhD students and look at some collaborative projects between the two countries. Very different health systems and very different situations which makes a little bit more exciting. So I, this is a photograph I took from the car travelling between to remote sites and this just puts it into context some the reasons why we’re interested in doing Telehealth, and I'll probably start by saying the Telehealth can be a lot of things and we describe Telehealth very generally as meaning you know the delivery of services from one point to another, where the patient happens to be in a remote location. But Telehealth can be done a number of ways as you'd appreciate and many of you have been involved or participated in Telehealth already, but, you know, generally we talk about real time applications, video conferencing, telephony is a very good example. Or store and forward which is email and posting information is another popular for example. So, it's really not that new, it's been around for a long time. We've been talking about it for a long time. I've been talking about it for about 15 years. Some in the room may have been talking about it for a lot longer but, it's been around for a while and we still up against some barriers and challenges affecting its uptake. So this picture here between Charleville and Cunnamulla is a about the two hundred kilometre stretch between two small towns in Queensland, and while traveling along here I passed four vehicles, and plenty of emu’s. No crocodiles, tortoises, different kinds of animals that I've never seen before and a couple of snakes so it this is just a demonstration at the remoteness to show you what typically happens. And this is the photograph is seen when you have an appointment down at the major hospital, the paediatric facility in Brisbane. The kids are in the car. We packed a lunch box and off we go for our appointment at the Royal Children's Hospital. ‘Are we there yet?’ you know, 747 kilometres. Not quite, we’ll be nearly there and we’ll stop soon. 

This is also an interesting map and many have you can access these from the ABS. This is a population mapping map and basically it details where people are, and it just illustrates the challenges we have here in Australia. You know, people are mainly, you know, grouped up in the city locations and the same could be said of our specialist services. Most specialist services are in the city areas, either in the main metro cities all along the coast. Not many of our specialists decide to live out on remote locations and that's why that adds to the challenge. Can Telehealth help? It certainly can. So in Australia with the population around 23 million people ,as I mentioned. A significant proportion of the population live within city areas but about one-third of the population live outside of those areas and that's why things really important that we think about a number of new ways, more creative or innovative ways of delivering services and changing our conventional models of care need to actually happen. So, transport costs are significant, and that doesn't matter where you go in Australia, here it's a big country. So, the expenditure for the government and also for the patient families is quite significant. Underneath all of this is a problem with equity of access. A key driver for Telemedicine is to give access to these health services - fair access. So, no matter where you choose to live, you should be able to access the best possible services available. So, we've got issues of disparity for those people living in remote locations and that's a good reason to do Telehealth. Patients have to travel, as I just mentioned. It's expensive and stressful, so we don't just want to look at the dollars but look at the time and inconvenience and the dislocation moving away from home to attend appointments. Some of these appointments could be four or five hours in the car and last for five minutes at the specialist hospital. These are the things that I think we need to critically look at and think can we do it better? And, of course, we've got visiting outreach programs which i think are excellent and tele-medicine is never going to get rid of those but tele-medicine, no, Telehealth can certainly support them. So tele-medicine, you know, has been around for more than 15 years. I know it's been around for a lot longer in the early 1900’s, when telecommunications became available. You know, that's when Telemedicine applications really emerged. It depends on the definition whether you want to get into an argument of when tele-medicine really started. Some argue that it went back to smoke signals, a long time ago and that was true when, you know, when we were transmitting information about disease between different tribes. But you know, looking at the developments that happened with NASA, that has been a big motivator to improve tele-monitoring exercises and giving advice to deal with healthcare. Improvements in telecommunications are happening all the time; you can’t keep up with the latest phone or the latest gadget. So, there’s a lot to do. This kind of view point was back in the early 1900’s, is it possible to get your local Doctor on screen? This is a little news clip. And then also there was a cartoon. Some of you may have seen it. It could just be possible that you can look at a screen and that specialist can look down your throat. Fancy that. 

So, my role in the Centre for Online Health and I will just introduce you a number of things. This presentation is going to talk about the work that we have done in the COH in Queensland, in partnership with The Department of Health, and a whole range of different sponsors of our network. It is quite interesting, in the sense that we have been mainly covering our paediatric environment, because we are physically based in The Royal Children’s Hospital and we had been since 1998. But, more recently, we have moved into the adult hospital, giving us the opportunity to do this type of work in an adult environment and also looking at services for geriatric patients. So, what does the COH do? We are a research department because we are a university department. We have teaching responsibilities and we also provide services. So that is a tri-part mission and it is a very interesting relationship between each. We are not a remote research department, that works in a lab with white lab coats. We actually get our hands dirty and work closely with clinician’s. I have a clinical background and many of us do in the team. And some of us also come with IT, management, administration or engineering backgrounds. So, it is a really good mix of people. What we are interested in doing is working mostly with clinicians to service models, different models of care. By providing services, we do that under service level agreements. That gives us the environment to do our research. We get ideas from the clinicians. And that is what propels some of the work that I am about to describe to you. The research and development is led by a range of different grants from places like the NHRC but also from different corporate groups and foundations. And we also do teaching, being a university, we can’t escape our teaching responsibilities and we offer a range of different courses in the area of E-Healthcare and Clinical Telehealth.

More recently, the NHMRC CRE in Telehealth, just to tell you in one minute about that. That’s a five year grant by the NHMRC and it’s designed to boost or develop search capacity in the area of Telehealth. So, we have five years to focus on building up a new group of PHD students and researchers, who will specifically look at Telemedicine. There are four main themes and there are some are some cross over themes as well involved in the CRE. So, many of these won’t surprise you as target areas. So, residential aged care facilities and aged care is one of the focus leads, led by Professor Len Grey, who is a CRA on this grant. The small rural hospitals is the theme that I am leading, and that just covers about everything in Australia, outside of the main city areas. Home care and also indigenous communities is another one that I am personally involved in with Dr Noel Hayman in QLD. So it’s about building a new knowledge base, looking at the issues, the barriers, the uptake and looking at building that capacity. There is a range of different things that we look at, in terms of the research, this isn’t a complex list, this is just a few examples. When people come to us and say ‘look, I want to do Telemedicine,’ there are a whole range of questions that we focus on, but, some of the underlying questions we are interested in are new applications, is technical requirements. You know, is this going to work in the situation. So, what information needs to be transmitted and shared? What’s the best method for sharing that information? So looking at quality, looking at security and privacy. Is it acceptable for clinicians and to the patients? Is it clinically safe? And also from a society point of view, you know, what does it cost? Is it going to save any funding and what are the overall benefits, particularly from a clinical and cost effectiveness point of view? 

Just recently the Lady Cilento Children’s Hospital just opened up. We spent 14 years in the Royal Children’s Hospital, so not far away. Two paediatric hospitals merged together. And this all happened in November just last year. Yeah, so this is very new. It’s an extremely large hospital. So, all of a sudden when we have seen the merger of two paediatric hospitals facilities first before moving into the areas of adult and geriatrics. For the last 15 years we’ve coordinated over 20,000 consultations through the Telemedicine program. That includes different situations where the patients are present, case discussions and also a range of different store and forward applications and some of those I’ll explain today. We don’t focus on just a few specialities. I think we’ve covered every single speciality in the hospital to date, to various degrees. So, some specialities, only a small amount of Telemedicine or very occasional and ad-hoc and some what we call the power users, and they just don’t go away. They are there every day, running clinics, and they are quite impressive. So, we spread or services out to about 110 sites, right throughout Queensland. Throughout Queensland, the department has a very large network of video conference systems. More than 3000, I think. It’s probably going up by 100 everyday at their rate, but there is certainly a lot of infrastructure. So, why don’t we look at the issues of perhaps, low up take and look at how we can improve the use of our existing infrastructure.

A key point about the service we’ve set up and that is the point of my PHD, which I did back in 2001-2004, was looking at Telehealth coordination. And one of the key reasons why I believe why Telemedicine wasn’t going where it ought to, was that we didn’t have systems in place to make Telehealth work. You know, we were boasting expensive and large infrastructure networks, but what we hadn’t thought about from a clinical perspective were the mechanisms and processes that had to be put into place behind the scenes to actually make Telehealth work. Outpatient departments and other departments have these processes to a certain degree. Some more will argue about their efficiencies but they are certainly there. So Telehealth is not just about saying ‘here is the system, here is a piece of software, do Telehealth.’ So our Telehealth model had dedicated coordinators that basically made the whole service work. They were our single point of contact. They received the referral, they organised all the appointments, they scheduled all the appointments, they provided technical support, collected medical records, documented the cases, organised follow-up appointments, and basically pulled it all together. So, our clinicians, in that sense, being in a central location, could come in, have the appointment, see the patient, then get on with work. So, we wanted to remove that one obstacle and that’s been working very well. There’s a whole range of sub-speciality services that we have focused on. In the bottom right hand corner is a cardiology consult, so linking up an ultrasound machine to the conferencing system meant that in site called McKay, which is 1000km’s north of Brisbane we could easily look at an ultrasound image without a paediatric cardiologist and make a diagnosis. So, that was some work done in the early stages of our program. We did about 190 of those cases and, in normal circumstances, these patients would be transferred. 

Now, a transfer for a newborn baby is expensive, let alone stressful for the family who has just had the baby. So, out of 190 cases, 4 were transferred down to Brisbane because of Telemedicine. So, I think that’s a good thing. The types of specialities we are dealing with - you’ll see some of the major groups here, psychiatry is our E-Kim’s program, our E-Child and Mental Health Service. That’s one of our largest areas, burns care, neurology, Ear, Nose and Throat and a whole range of different areas. But that will give you an indication of the type of specialities. We have been conducting these services, I said, for over 15 years. Don’t get too alarmed about the drop in figures towards the end there.I initially did when I did this graph but there is a good reason behind it. The E-Kims or Child psychiatry service has now relocated to their own clinic areas and they manage this service by themselves. So, we’ve cut that out of our program now and they run independently, which is a very healthy sign for that service. 

This slide here in Queensland shows you the destination where many of our services have been delivered. And this is an example of one of our studios where our child psychiatrist is consulting with a patient and a team member at a remote site. This is a burns consultation, so he is sending images, using video conferencing, which is used all the time by our burns team. Burns, getting burns into Telehealth was a bit of a jump. Our surgeons, initially didn’t want anything to do with it, because the only way to do burns care is to bring them down to us. And with a little bit of encouragement and arm twisting we were able to let them have some of their meetings in a medicine environment, they started talking to other on the video conference screen and then they decided that this isn’t too bad after all, we might give it a shot. And, since then, they have been taking it on and running their clinics and in a way it will competitive in the way of patients they have in each of their clinics. And, I have since sat in on a conference and heard one of the burns consultants, who leads the trauma group and say, ‘back in 2001, I had this brilliant idea.’ And, for me, that is a sign of success, if you give it back to the clinicians. Interestingly, what does Telemedicine do, do? Outpatients and transfers, well I find this quite interesting because, although this is an older slide, we are still seeing similar patterns. About 15-17% of burns outpatients are now being managed at distance and this is particularly focussing on our country patients. The other very interesting thing too is, looking at the cases. So, in the last 15 years we have done almost 2000 burns consultations and what I did was look at all these cases to work out where they are coming from. So, looking at the demographics - the average distance was around 600 km’s so it just gives you an idea of where these people are coming from. I have worked in the burns unit before and I can easily recall patients coming in for very brief appointments, after hearing their stories of about one or two days travel, just to come in. And these are appointments happen every three months, six months, 12 months. So, average distance, 600. So, what I did I kind of multiplied that out by the number of cases per area, and it came up to 2.8 million km’s. Which is quite a lot of savings. Even more, just to put that into context, so that people know, that is four return journeys from earth to the moon.

So, we have been doing work in diabetes as well, in a range of different areas. We provide patient education, support for paediatricians and support for a range of different allied health therapists to our patients with diabetes, general surgery, burns care is one example, but that has opened up a whole range of different areas including ears, nose and throat, vascular surgery, orthopaedics and general surgery. The general surgery is quite interesting, because all the pre-op appointments, we are trying to get as many of them, certainly outside of Brisbane, to come in and have a video conference. And that is working extremely well. You can see a bit of a shift back in 2010, 2011, on the chart there and that is because we brought out a new coordination model and we set up different regulations for clinics for all of our doctors and that model is working extremely well. That has basically changed from 19 consults to about 160 consults per year for our general surgery teams and we have written a number of papers on that.

Home support. Some of our work is trying to get patients out of hospitals and into their homes, and this is working very well. We are talking about a very small cohort of patients, particularly our palliative care group. We try to get them out of our oncology units and medical units into the home, where they much more comfortable, with mum and dad and the kids and the pets, aunts and uncles, everything else that comes with that. But, most important thing, they are in a comfortable environment. We use a range of different techniques, about 10 years ago, when we started doing this work, it was hard to find a family that had a computer or internet. Now most of our families in these locations have four or five computers and a very good internet connection. Probably better than the one I have in Brisbane. So, it is improving. It is a dynamic field, Telemedicine, because the actual infrastructure that we have available to us, is improving all the time. 

We actually brought clown doctors out by Telemedicine as well and wrote a paper, and this is one of the first in the world kind of. So, if the patients at this busy hospital, do clown doctoring, why can’t our country patients get it as well. So, the clown doctors come in and they do their entertainment and they wrap our video conferencing systems up in toilet paper and they do a whole range of things. Their job is to really entertain the kids, no matter where they are, whether they are in the hospital or they are out in our remote locations. The other area I wanted to tell you quickly about it, was our robots, which began in 2004. We don’t use our robots anymore, but it did demonstrate a very important point. The robots were designed to support a remote hospital that had no paediatrician and what we decided to build something that was not only child-friendly but also could be taken to the bedside. This is the idea about wireless, mobile video conferencing. Keep it very simple. So, what we did is, we designed with fibreglass, kind of a robot casing. The video conferencing system was inside this and there was nothing else special about it. It has some wireless networking, it is really, really simple. These robots were operated from Brisbane. So, we could turn them on and off. All that had to happen at the other end was the nurse or doctor just wheeled it to the bedside and then the doctor would appear on the screen. They could do the consult, so we did ward rounds twice a day with the paediatrician. The ward that we focused on had no paediatrician, despite a ward full of kids, that needed one. And we were able to link up junior doctors and nurses and monitor them twice a day. We built a few robots in our time, to try different models and techniques. Now the Queensland health system operate a very nice clinical system, as one of their standard products in their line.

I haven’t come across this complaint yet. So, ears, nose and throat is quite interesting as well. What can we do with kids who have ear problems? Again, it’s a typical problem, kids come down with their suitcase and their toothbrush, they see an ear, nose and throat surgeon and yes, you need a tonsillectomy and mum and dad are excited, we’ll send you a letter for your operating room appointment. They thought it was going to happen, there and then, didn’t they? So, no, that’s not the case. What we are doing is, pre-assessment again, so we are using a video endoscope, with a nurse that is trained at the other end. Ear, nose and throat surgeons and doctors and their teams will look at these cases and discuss the case with their paediatrician, talk to Mum and Dad, talk to the kids involved. If surgery is required, they are put onto the list and that at least saves one appointment. Much of the follow up is also being done by video conference, so a simple grommet check-up can take about 90 seconds. So, if I am travelling a long distance for a 90 second appointment after having waiting an hour and half in outpatients, I wouldn’t be too impressed. Just to - for those who haven’t seen the type of images that you can get, this is just - ignore the background noise - this is looking inside the ear drum, inside the ear, so looking at an ear. If you want to look at the ear, eyes and nose and also in the mouth. So, these are videos can be pre-recorded or shared live by video conference. The idea of collecting these images gave me another idea, back in 2004 when I visited an Aboriginal community called Cherbourg. Cherbourg is a small Aboriginal of about 1000 kids. Very high prevalence of ear disease, anecdotally about 90% of the kids in the community have ear disease. The World Health Organisation say about 40-42% is classified as epidemic, so something wasn’t quite right. So, what we did is we took the system out to the remote community, set an outpatients. This is just a testing phase. We got all the kids to come up and have a look at their ears. All of a sudden, things changed. If you think about it from the perspective of a patient, it doesn’t matter if you are of Indigenous background or not. All of a sudden, visualising or seeing inside your ears or inside your throat or looking at a condition makes a huge difference. People, all of a sudden, started to take ownership. So, instead of hearing a fancy diagnosis from a clever ear, nose and throat surgeon, all of a sudden we could see the problem on the screen. And that was a very interesting kind of development. In the bottom left hand corner, were a group of kids looking in their ears. That was quite entertaining. Some of the things they said to me whilst I was doing it was very entertaining, got a few surprises along the way, but most of importantly they kind of thought this was pretty cool. We could do this. So, we had an idea. Rather than us do this work, why don’t we get the Indigenous community to do the work themselves and we just support them. So, we built a mobile clinic. A mobile hospital which had everything inside it to do all the screening. So, a videodiscope, computers to store all the images, an SG connection, a database that we built. So, the information is collected by the Indigenous worker, who is in the bottom left hand corner, his name is Pickle. He’s famous, I think he is famous. He’s one that runs this program, not us. We are the invisible people behind the scenes who provide all the support. But it is his service. And Cherbourg know him as the one running the service. Beautifully accepted by the community. You open it up with all the traditional processes and we had the elders give a couple of talks about their stories and how important this was. So, it was a very good demonstration of community acceptance. All of these images are collected, they are viewed by an ear, nose and throat surgeon in Brisbane, usually once a month and then all the information is used to support an outreach program, where now our team go out and do surgery out in that community. So, very high community acceptance was demonstrated by our consent rate. When I began this program back in 2008, we received funding for the vehicle and we got the green light to start. Our big pressure point, really was - was the community going to consent to it. I knew that they were positive and on board. We had almost 100% consent rates. We had teachers going to doors, door knocking. We had people going down the road to the park, getting people to sign forms. We didn’t have to do any of that, the community did it, because they wanted it. This vehicle goes around to 32 schools in the area now, mainly in Cherbourg, but also in peripheral schools. Screening rates have increased, waiting times have increased – that’s a bad thing – has gone down. Interestingly the movement of patients as you would expect has also changed. So, there are less children having to travel to Brisbane and more services being provided in the community. Let me show you that. So, before we started the program, there were about just under 40% of the kids being screened. I remember, anecdotally about 8 or 9 out of 10 kids had some type of ear disease. We have improved screening rates to over 85% and that has been consistent since the program started. The waiting time we have changed from about 73 days to around a month. Now this is very interesting, because the policy according to the Brisbane Hospital was about 34 days. So, I was breaking the rules. But anyway they are getting an excellent service and it is on par with what we are getting in the city environment.

The other very interesting thing, as you would expect, is that the delivery of surgical procedures has certainly shifted in favour of the group in Cherbourg and this is a much better model. I remember having the discussion with the district manager once, who said to me, "look, have a look at this waiting list for operating theatre," and the failure to attend rate was normally 100%, you know 12 kids, 100% failed to attend. That costs money, it costs resources, it’s inconvenient. But also think of it from that patient’s perspective, they are not getting the service they need, because they couldn’t physically get down. So, this team now travel out to Cherbourg and do most of the surgeries out in Cherbourg that are deemed safe to do. So, activity to date is encouraging. We’ve got children who are being registered into the program all the time. Our screening rates are being maintained and our assessments are steadily increasing. 

So, another project is called Healthy Regions, which takes a different approach to doing Telemedicine and this is an approach that is taken out to the community to look at the whole community approach. And it is a program that I had funded by QDC who wanted us to focus on three particular towns that they were working in: Dolby, Chinchilla and Miles. And what makes this program particularly interesting is that, my focus wasn’t just on the hospital system, it was on a whole range of different systems and think it is an important thing with Telemedicine, is that you just don’t go in with one sided, that you are going to provide a hospital to hospital service. It’s about engagement and links with general practice, with Aboriginal medical centres, with schools and with hospitals. It’s complex. You are dealing with lots of different people, different personalities, different systems, different responsibilities but our focus in this area, although it is a relatively slow one in the scheme of things, is try to bring all of that together and improve the communication that happens between all of those service providers. So, we’ve run a number of community events. We’ve run launches in each of these areas to make people aware of Telehealth. We have done letterbox drops, interviews with the general public. We interviewed about 60 patients, through interviews, you know, so if you ever heard some strange looking guy, chasing some in the shopping centre in Dolby, that was me. But the interviews were done for a good reason. We have just also written up a paper, which is under review at the moment, looking at understanding and perceptions of Telemedicine. And, as you may expect, patients knew very, very little about Telemedicine. They just didn’t know. And I think that is another very important area that we need to look at, public awareness. So, we’ve got a campaign which is called Ask for Telehealth. Now this is a cautious campaign because I think that one of things we need to be careful about, is not to have a big tsunami of people running into general practice and hospitals looking for Telemedicine. If the Telemedicine isn’t there. Otherwise it is going to cause a lot of disappointment from the patient perspective. It is going to cause a lot of angst and irritation from the service provider if they don’t have Telemedicine. So I think it is a balancing act. So we are focusing on the service providers. We’re feeding information to the general public, and trying to bring it together on balance. And it is a bit of a juggling act.

So, I just wanted to run through very quickly an example of a study that we did, which is a cost and minimisation study. And I don’t want to go through a health economics lesson, that’s not the point of this. But it is important for us to be looking at our Telemedicine services from an economic angle. And economics can be looked at from a range of different perspectives. You can look at it from the perspective of the health service provider. You can look at it from the patient perspective, which is a common one. But also more broadly from society’s perspective. You know, what does it cost for us to invest in this and what are the potential savings, if there are any. So this is an example of our child psychiatry run over a 30 month period. And I compared the cost of providing these services done by Telemedicine. The services provided during outreach, where the person travelled to the site and also the costs if the patient travelled down to Brisbane. And putting all of those costs, the fixed and variable costs into there, you are able to work out what the average cost is. But the marginal cost is the one that we are particularly interested in. So the marginal cost is assuming, the infrastructure is in place and this is what it would cost to do an appointment. So the face to face, owing mainly to the cost of travel was about $1000. And out Telemedicine option was about $190. So, a reasonable difference. Once you have that information, then it’s also important to try to plot it and to try and work out where your threshold point or where your breaking even point is. And the breakeven is determined on volume of work. So, if you are planning a Telemedicine operation that would have relatively low volume, then you may want to consider what it costs to establish, over the costs of the savings. So, in our case, we were easily breaking even. So, our threshold point was on a different plane. But the important thing here was, if our activity had exceeded our savings would have been greater. If our activities had been about 100 consults, we would have been looking at maybe a visiting outreach program, instead of Telemedicine. 

So, just overall, the Tele-paediatric service there, the coordination there behind the scenes is very, very important. It’s been a very important driver for the work that we have been doing over the last 15 years. It’s an important model that supports everybody involved and it’s not just the clinicians, but it is also the people involved from the appointment end, with our patients and our parents. It is one of the largest reported services of its kind, in terms of the breadth of services offered and, most importantly, it is demonstrating a way of trying to improve equity of access to services. 

So, I want to take a jump from paediatrics and child health into the adult arena, just briefly, and in 2012, we had an opportunity to work with the PA hospital to look at adult services and the idea there was to try and replicate what we had done in paediatrics and try and move that into an adult environment. This is generally the model and we use this model for a range of different services but it just illustrates that this is the functionality of the centre that we have constructed. It’s not just about providing reception services and helping people with Telemedicine. But you will see on the left hand side there under ‘service establishment’, there are a lot of things that you to focus on when you are trying to build or grow a Telemedicine operation. There is working with the clinicians, there is change management, looking at decision support systems, electronic records. There is a whole lot of work that needs to be done with these people. So, we’re working with a number of different groups, and most importantly, the PA Telehealth centre is distributing services, not only at the hospitals but now into Aboriginal medical services and also into general practice. 

The thing I like the most, in contrast to our work at The Children’s where we started in a concrete slab, there was two or three of us in the centre at The Royal Children’s with a jar of Nescafe, we have grown that obviously, but with the PA we had an opportunity which you don’t get very often and that was ‘design your own,’ you know, what do you want to do with your space. So, the CEO of the hospital carved off a section of the library which was under used and we had some space to work with. So, this was our floor plan we wanted some dedicated studios. We wanted a very nice reception area, where coordinators could work and monitor the work, like a bit of a docking station. We wanted space for our researchers and academics who are looking at innovation, working with clinicians and reasonable office space for meetings. So, just to, because I can’t all walk you through the centre at the moment, if you are in Brisbane everyone, I am more than happy to give you a tour. But that’s our front reception. You will walk through. A view from our coordination station there, you’ve got these consult rooms that are all set up. We have got some meeting rooms with standard video conferencing. This is an example of our consult rooms. So, every consult room is set up in exactly the same way. A couple of the rooms have a couple of different pieces of equipment, depending on the specialties, but the idea is especially if you go into a consult room, 1, 2, 3, 4, 5 or 6, you are going to be sitting in very similar environment and you are going to know where everything is. The other important thing is the screens on the desks, they act as a bit of a console, we call it our cockpit. So, all the electronic records and the information that people may want, sits in that screen. It needs to accessible, very easy for the clinicians. From the viewing perspective, when you are the patient, you don’t see any of those screens, they are just out of view. So, all you will is the consultant’s face. In terms of just activity, just to share with you in the last three years, the activity is increasing steadily. I also said that this would take about five years before we would realise the activity increasing. Our centre itself has capacity to do around 8000 consults per year. But we are years away from doing that, because there is so many processes to get right, before we are able to reach that volume. So, there is a number of specialities. Geriatrics is dominating the group. But there are lots of other specialities which I haven’t shown on the list here that we are currently working with and developing business cases and talking to the clinicians about what they can achieve. So, another example of the work, which is slightly linked to the PA is your Tele-geriatrics. My director, Professor Len Grey, is one of the leads in this program of Resicare. He and I helped develop this model about four years ago and it has now moved into a commercial business run by Uniquest. The idea here is to provide Telemedicine services into residential aged care facilities on a routine basis. So, we call that an academic Telehealth service because we are always embedding research and evaluation into it to see what works and what doesn’t. It is operated jointly by the Centre for Online Health and also by the Centre of Research and Geriatric Medicine. So this works in such a way that we have a complex or comprehensive geriatric assessment. These assessments are done in advance, they are done by the nurse caring for the patient. These are available online and are used by the geriatrician. We try to set these up in such a way that we have weekly clinics available to each of the RECF’s and they book their new cases in and also review cases. So, the structured assessments processes, the intertied software, which is put into the online version of CGA which is something that we have also built. The work that we are doing is not just geriatric support, the idea is to get the geriatric support working really well, and humming along, before we start bringing in other sub-specialities. So, the model is, bring in other geriatric services where it is much needing in nursing homes. Once we get economies to scale and once we develop the number of sites that we have available, then you can bring some other sub-specialities into play. This is just an example of Len on the TV screen and a patient in the bed. There are a number of ways that we do, do this. We use mobile video conferencing, but we also use room based systems, depending on what the facilities prefer and depending on what infrastructure is available. And, from the perspective here, looking at the screens, similar process to having the monitors available for the video conferencing. Very interesting that this just demonstrates that the importance of having records, apart from the fact that our doctors usually carry around half a dozen passwords, which I think is unfortunate and really a problem that we have. I also give them access to the internet, and that has proven quite useful. Interestingly, when you are a looking at gait or physical movement of a patient, getting on to google street view, you can start asking questions about their steep stairs at the front of the house. And you get this puzzled look on their face. Like ‘how did you know?’. So, the Resicare model is about supporting residential aged care facilities and sites that normally don’t have access to specialist geriatric services. It is certainly supporting skilled development. So engaging nurses and doctors with each other certainly has its benefits. We’re doing a study at the moment, so it’s easy for me to stand up and say this is fantastic but we have a randomised control trial at the moment, funded by NHRMC to look at exactly that, to look at the clinical outcomes and the benefits and this study is underway and the intervention stage or recruitment stage finishes towards the end of next year. 

So, I’ve given you a fair bit of information to digest on a number of the services. One of things I wanted to share with you too, our role in the Australasian Telehealth society, my role as the President and Tory as the Vice President is to really to provide an opportunity to provide or a society for people to collect information or access information. My feeling, nationally and internationally, is that there is so much really good information out there, it’s just where do you start? You know you can ring a certain person or email them but we’re trying to set up a repository or a single point where people can get that information and share and engage. So it is about getting together and sharing that community and I encourage people to be part of the society. There is a website there where you can get information. But we are interested in getting everybody’s experiences and there is excellent work, as we discover, happening in every state and territory around Australian and also in New Zealand, which we partner with. So, certainly get involved, if you have a look at the website, join the mailing list. The other important tip I will give you is we’ve got our conference coming up, which I will show you little bit later on. If you come along to the conference, you get free membership, so don’t sign up yet. Come along to the conference and we are going to get you free… (laughter) no, you get membership. 

So, just back on to the actual process of doing Telemedicine is that doing Telemedicine, as I said before, is not about putting in boxes and wires and expecting it to work. You know, Telehealth is a much more engaging process, where we are looking at change management, working with people, trying to understand how we change old, conventional models to new models that perhaps are more efficient. So, it’s really important that we kind of sit together and try and work out what the best model is, you know, we have got face to face, we’ve got outreach, video conferencing, you know, what is the most suitable model? And what don’t be scared about change. Another important point is that you need organisational support and I certainly get that strong feeling here in Victoria. We have it in QLD but having organisational support, if you don’t have that, it makes life very difficult. Very, very difficult. And the support, mind you, is just not top level support, it is also clinician-driven support. You need the clinicians on board and want them to feel empowered and responsible for doing that. So, there are plenty of changes happening in our environment you know, in telecommunications, and that and people need the change the way that they work. So, this is not an exhaustive list. This isn’t everything you need to know about Telemedicine and what you are required to do Telemedicine well, but, there are a whole range of things that we tend to have to go through our checklist and I will share a couple of those things with you. You know, clinical resourcing, you know it is a great idea to do Telemedicine, but if you don’t have the staff it makes it really hard to do. Is this a case of providing a new service or implementing a new service or complimenting or substituting a service. So they’re the things that we need to think about. Looking at secure funding. Traditionally, Telemedicine has been blamed for picking up lots of small projects and a bit of a job about pilots for Tory Wade, more pilots for Telemedicine than Qantas. But I think it is really important that we now are seeing funding models emerging in Australia that are actually supporting Telemedicine. So, that is a very positive sign. Getting referral pathways very clear and understanding who does what. And how do you actually generate a referral is very important. Looking at hosting services. Telemedicine, by its very nature, because it involves more than one site, all of a sudden requires people at both ends. So, you can’t forget about the other end when you are doing Telemedicine. It does impose time requirements and you do need to develop skills and training for people at the other end. Looking at the scope, what can you do and what can’t do is very important to identify. Incentivising, we have seen a number of different financial incentives put into place but also the method of operation is also very important. So, engaging from remote sites, no point it being in a nice big city hospital, saying we are going to do Telemedicine. You are going to have it, whether you like it or not. That doesn’t really work. You need to engage with those groups. Another specific check list is this one here, so I mentioned funding before, it’s very, very important and there is some funding that’s now available, obviously through the Medicare system - Telehealth items, that was introduced back in 2011. But the other very important responsibility that we have when we are developing Telemedicine, this is what the Centre for Online Health enjoys doing in a clinical environment, is that you get to engage with clinicians and understand exactly what they want. So, take a step back, take a breath and think, what are we trying to achieve here, what are the clinical requirements, what are you trying to do and what are the processes? I think Telemedicine, with the change management, is all about reengineering. So, we’re taking an old hospital system or a health system which can’t keep up with innovation. We’ve got new funding methods that are being brought in, we’re ahead here but we’re being dragged along by the system. So we have got to try and change that and influence that. I’ve talked about incentives. You need clinician support and the big one there, that I am not going to answer in the time that I have left is electronic records. This is a real challenge. Making sure we can share records, document efficiently and make sure that we’ve got the information available to do our consultations efficiently.

This is a slide taken from a paper published just last year by Tory and her team. Just looking at Medicare. So, uptake is steadily increasing, as you see there, in the scheme of things, relatively small. From a Federal Government perspective, I think Telemedicine accounts for less than 0.02% of all activity currently, so if you compare that to face to face. I did a study a number of years ago that looked at tele-psychiatry and if you compared face to face, appointments to the Telemedicine it was about 0.02%. So, very small in the scheme of things. I am not saying that to be negative because in time, this illustrates that in time there is a steady increase in the uptake of Telemedicine in Australia and that’s encouraging. So, a couple of practical tips to, kind of finish off. Develop your systems, develop your Telehealth systems systematically. Start small and gradually develop. Don’t get in there with this huge ‘I’m going build Victoria or build Queensland and I am going to do it by Sunday afternoon’. It just doesn’t happen. Don’t forget about the clinician’s and the patients. You know, make sure there is very good engagement between them. You may be an expert in Telemedicine but there is a lot of different aspects that need to be played out. I encourage you, when the opportunity arises, and we’re certainly happy to assist with this, but take the opportunity to report your work, all the good things that you are doing. From my own personal perspective, you know you are always astonished when you hear of different programs happening that you have never heard about or you have never read about. Its only when you bump into someone and say ‘look, I’ve being doing this for five years’ and you think it is brilliant and if you can, please try to write it up and try to get it in a report or on a website or in a publication. There a number of different areas that I encourage you to look at, from an evaluation perspective, and they’re listed there and if you are relatively new to the field, have a look around. So read papers or look at websites, you know, talk to us about what’s been done and what’s worked. Try to make your move, based on those services that have succeeded, rather than those that have failed. I have come across many different examples where someone has said that ‘I’ve done this, I’ve just spend $1.2 million dollars, you know we thought the patients would love it but it was an absolute disaster.’ And you think ‘well quite a few people have done the exactly that and reported that it has been a disaster.’ So have a look at the reports and learn from other’s experience. We run a meeting called Successes and Failures in Telehealth, which I will say, as a day claimer, is coming up in November in Brisbane. We have been running these for 15 years. And what I do is, I purposely get people to get up on the lecture and many people today here have actually done that very well, to talk about successes or failures or a bit of both, in Telehealth. It is always good to get up and talk about the "F" word. You know people often want to get up and talk about successes and look how great we are, but it is also really important to get up here and talk about those things that we thought were going to work but just didn’t go our way. And that’s what really, I think, will help propel and assist with the development of Telemedicine. 

So, just in conclusion, conventional models of health care are really not sustainable We need to change and change is inevitable. We kind of need to look at our practices and Telemedicine or Telehealth, in its own right, is a disruptive technique. It’s about changing. We are going to be forced to change the way we work in order to be able to deliver the services that we have to in the very near future. So, very importantly, it’s not just a single lined approach, you have got to look at it from a whole of system approach, in order to develop your successful uptake of Telemedicine. So, ultimately, to finish up on this point here is, you know, a key driver, why are we here? We are here to try and give our patients the absolute best access to specialist services as we can, irrespective of where they happen to live. And that goes for Queensland, that goes for Victoria, it goes for every state and every state in the world. Thank you.

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Establishing and managing paediatric and adult telehealth services: practical experience from Queensland, Presentation by Associate Professor Anthony Smith, Centre for Online Health

Good morning, everyone, and look - thank you very much for the opportunity to present today. I’d like to thank the Department for supporting my trip here and also to thank Paulette, who has kind of secured me to this role late last year and said look we need to come along and talk about your work and Telehealth and so we started to talk about a few topics and every topic I mentioned she said, "yes we'll have all that." So, I said, "how long do I have?" And she said "about 45 minutes." So went away thinking, ‘how am I going to put fifteen years of work into 45 minutes?’ and I'm going to give it a shot.

So work at the Centre of online help in the Centre of Queensland and I have a number of other positions and academic responsibilities, one being in the CRE of Telehealth, which has recently been established in Australia and, more recently, a role in Denmark as well. I visit Denmark every year and I'm beginning to take on some PhD students and look at some collaborative projects between the two countries. Very different health systems and very different situations which makes a little bit more exciting. So I, this is a photograph I took from the car travelling between to remote sites and this just puts it into context some the reasons why we’re interested in doing Telehealth, and I'll probably start by saying the Telehealth can be a lot of things and we describe Telehealth very generally as meaning you know the delivery of services from one point to another, where the patient happens to be in a remote location. But Telehealth can be done a number of ways as you'd appreciate and many of you have been involved or participated in Telehealth already, but, you know, generally we talk about real time applications, video conferencing, telephony is a very good example. Or store and forward which is email and posting information is another popular for example. So, it's really not that new, it's been around for a long time. We've been talking about it for a long time. I've been talking about it for about 15 years. Some in the room may have been talking about it for a lot longer but, it's been around for a while and we still up against some barriers and challenges affecting its uptake. So this picture here between Charleville and Cunnamulla is a about the two hundred kilometre stretch between two small towns in Queensland, and while traveling along here I passed four vehicles, and plenty of emu’s. No crocodiles, tortoises, different kinds of animals that I've never seen before and a couple of snakes so it this is just a demonstration at the remoteness to show you what typically happens. And this is the photograph is seen when you have an appointment down at the major hospital, the paediatric facility in Brisbane. The kids are in the car. We packed a lunch box and off we go for our appointment at the Royal Children's Hospital. ‘Are we there yet?’ you know, 747 kilometres. Not quite, we’ll be nearly there and we’ll stop soon. 

This is also an interesting map and many have you can access these from the ABS. This is a population mapping map and basically it details where people are, and it just illustrates the challenges we have here in Australia. You know, people are mainly, you know, grouped up in the city locations and the same could be said of our specialist services. Most specialist services are in the city areas, either in the main metro cities all along the coast. Not many of our specialists decide to live out on remote locations and that's why that adds to the challenge. Can Telehealth help? It certainly can. So in Australia with the population around 23 million people ,as I mentioned. A significant proportion of the population live within city areas but about one-third of the population live outside of those areas and that's why things really important that we think about a number of new ways, more creative or innovative ways of delivering services and changing our conventional models of care need to actually happen. So, transport costs are significant, and that doesn't matter where you go in Australia, here it's a big country. So, the expenditure for the government and also for the patient families is quite significant. Underneath all of this is a problem with equity of access. A key driver for Telemedicine is to give access to these health services - fair access. So, no matter where you choose to live, you should be able to access the best possible services available. So, we've got issues of disparity for those people living in remote locations and that's a good reason to do Telehealth. Patients have to travel, as I just mentioned. It's expensive and stressful, so we don't just want to look at the dollars but look at the time and inconvenience and the dislocation moving away from home to attend appointments. Some of these appointments could be four or five hours in the car and last for five minutes at the specialist hospital. These are the things that I think we need to critically look at and think can we do it better? And, of course, we've got visiting outreach programs which i think are excellent and tele-medicine is never going to get rid of those but tele-medicine, no, Telehealth can certainly support them. So tele-medicine, you know, has been around for more than 15 years. I know it's been around for a lot longer in the early 1900’s, when telecommunications became available. You know, that's when Telemedicine applications really emerged. It depends on the definition whether you want to get into an argument of when tele-medicine really started. Some argue that it went back to smoke signals, a long time ago and that was true when, you know, when we were transmitting information about disease between different tribes. But you know, looking at the developments that happened with NASA, that has been a big motivator to improve tele-monitoring exercises and giving advice to deal with healthcare. Improvements in telecommunications are happening all the time; you can’t keep up with the latest phone or the latest gadget. So, there’s a lot to do. This kind of view point was back in the early 1900’s, is it possible to get your local Doctor on screen? This is a little news clip. And then also there was a cartoon. Some of you may have seen it. It could just be possible that you can look at a screen and that specialist can look down your throat. Fancy that. 

So, my role in the Centre for Online Health and I will just introduce you a number of things. This presentation is going to talk about the work that we have done in the COH in Queensland, in partnership with The Department of Health, and a whole range of different sponsors of our network. It is quite interesting, in the sense that we have been mainly covering our paediatric environment, because we are physically based in The Royal Children’s Hospital and we had been since 1998. But, more recently, we have moved into the adult hospital, giving us the opportunity to do this type of work in an adult environment and also looking at services for geriatric patients. So, what does the COH do? We are a research department because we are a university department. We have teaching responsibilities and we also provide services. So that is a tri-part mission and it is a very interesting relationship between each. We are not a remote research department, that works in a lab with white lab coats. We actually get our hands dirty and work closely with clinician’s. I have a clinical background and many of us do in the team. And some of us also come with IT, management, administration or engineering backgrounds. So, it is a really good mix of people. What we are interested in doing is working mostly with clinicians to service models, different models of care. By providing services, we do that under service level agreements. That gives us the environment to do our research. We get ideas from the clinicians. And that is what propels some of the work that I am about to describe to you. The research and development is led by a range of different grants from places like the NHRC but also from different corporate groups and foundations. And we also do teaching, being a university, we can’t escape our teaching responsibilities and we offer a range of different courses in the area of E-Healthcare and Clinical Telehealth.

More recently, the NHMRC CRE in Telehealth, just to tell you in one minute about that. That’s a five year grant by the NHMRC and it’s designed to boost or develop search capacity in the area of Telehealth. So, we have five years to focus on building up a new group of PHD students and researchers, who will specifically look at Telemedicine. There are four main themes and there are some are some cross over themes as well involved in the CRE. So, many of these won’t surprise you as target areas. So, residential aged care facilities and aged care is one of the focus leads, led by Professor Len Grey, who is a CRA on this grant. The small rural hospitals is the theme that I am leading, and that just covers about everything in Australia, outside of the main city areas. Home care and also indigenous communities is another one that I am personally involved in with Dr Noel Hayman in QLD. So it’s about building a new knowledge base, looking at the issues, the barriers, the uptake and looking at building that capacity. There is a range of different things that we look at, in terms of the research, this isn’t a complex list, this is just a few examples. When people come to us and say ‘look, I want to do Telemedicine,’ there are a whole range of questions that we focus on, but, some of the underlying questions we are interested in are new applications, is technical requirements. You know, is this going to work in the situation. So, what information needs to be transmitted and shared? What’s the best method for sharing that information? So looking at quality, looking at security and privacy. Is it acceptable for clinicians and to the patients? Is it clinically safe? And also from a society point of view, you know, what does it cost? Is it going to save any funding and what are the overall benefits, particularly from a clinical and cost effectiveness point of view? 

Just recently the Lady Cilento Children’s Hospital just opened up. We spent 14 years in the Royal Children’s Hospital, so not far away. Two paediatric hospitals merged together. And this all happened in November just last year. Yeah, so this is very new. It’s an extremely large hospital. So, all of a sudden when we have seen the merger of two paediatric hospitals facilities first before moving into the areas of adult and geriatrics. For the last 15 years we’ve coordinated over 20,000 consultations through the Telemedicine program. That includes different situations where the patients are present, case discussions and also a range of different store and forward applications and some of those I’ll explain today. We don’t focus on just a few specialities. I think we’ve covered every single speciality in the hospital to date, to various degrees. So, some specialities, only a small amount of Telemedicine or very occasional and ad-hoc and some what we call the power users, and they just don’t go away. They are there every day, running clinics, and they are quite impressive. So, we spread or services out to about 110 sites, right throughout Queensland. Throughout Queensland, the department has a very large network of video conference systems. More than 3000, I think. It’s probably going up by 100 everyday at their rate, but there is certainly a lot of infrastructure. So, why don’t we look at the issues of perhaps, low up take and look at how we can improve the use of our existing infrastructure.

A key point about the service we’ve set up and that is the point of my PHD, which I did back in 2001-2004, was looking at Telehealth coordination. And one of the key reasons why I believe why Telemedicine wasn’t going where it ought to, was that we didn’t have systems in place to make Telehealth work. You know, we were boasting expensive and large infrastructure networks, but what we hadn’t thought about from a clinical perspective were the mechanisms and processes that had to be put into place behind the scenes to actually make Telehealth work. Outpatient departments and other departments have these processes to a certain degree. Some more will argue about their efficiencies but they are certainly there. So Telehealth is not just about saying ‘here is the system, here is a piece of software, do Telehealth.’ So our Telehealth model had dedicated coordinators that basically made the whole service work. They were our single point of contact. They received the referral, they organised all the appointments, they scheduled all the appointments, they provided technical support, collected medical records, documented the cases, organised follow-up appointments, and basically pulled it all together. So, our clinicians, in that sense, being in a central location, could come in, have the appointment, see the patient, then get on with work. So, we wanted to remove that one obstacle and that’s been working very well. There’s a whole range of sub-speciality services that we have focused on. In the bottom right hand corner is a cardiology consult, so linking up an ultrasound machine to the conferencing system meant that in site called McKay, which is 1000km’s north of Brisbane we could easily look at an ultrasound image without a paediatric cardiologist and make a diagnosis. So, that was some work done in the early stages of our program. We did about 190 of those cases and, in normal circumstances, these patients would be transferred. 

Now, a transfer for a newborn baby is expensive, let alone stressful for the family who has just had the baby. So, out of 190 cases, 4 were transferred down to Brisbane because of Telemedicine. So, I think that’s a good thing. The types of specialities we are dealing with - you’ll see some of the major groups here, psychiatry is our E-Kim’s program, our E-Child and Mental Health Service. That’s one of our largest areas, burns care, neurology, Ear, Nose and Throat and a whole range of different areas. But that will give you an indication of the type of specialities. We have been conducting these services, I said, for over 15 years. Don’t get too alarmed about the drop in figures towards the end there.I initially did when I did this graph but there is a good reason behind it. The E-Kims or Child psychiatry service has now relocated to their own clinic areas and they manage this service by themselves. So, we’ve cut that out of our program now and they run independently, which is a very healthy sign for that service. 

This slide here in Queensland shows you the destination where many of our services have been delivered. And this is an example of one of our studios where our child psychiatrist is consulting with a patient and a team member at a remote site. This is a burns consultation, so he is sending images, using video conferencing, which is used all the time by our burns team. Burns, getting burns into Telehealth was a bit of a jump. Our surgeons, initially didn’t want anything to do with it, because the only way to do burns care is to bring them down to us. And with a little bit of encouragement and arm twisting we were able to let them have some of their meetings in a medicine environment, they started talking to other on the video conference screen and then they decided that this isn’t too bad after all, we might give it a shot. And, since then, they have been taking it on and running their clinics and in a way it will competitive in the way of patients they have in each of their clinics. And, I have since sat in on a conference and heard one of the burns consultants, who leads the trauma group and say, ‘back in 2001, I had this brilliant idea.’ And, for me, that is a sign of success, if you give it back to the clinicians. Interestingly, what does Telemedicine do, do? Outpatients and transfers, well I find this quite interesting because, although this is an older slide, we are still seeing similar patterns. About 15-17% of burns outpatients are now being managed at distance and this is particularly focussing on our country patients. The other very interesting thing too is, looking at the cases. So, in the last 15 years we have done almost 2000 burns consultations and what I did was look at all these cases to work out where they are coming from. So, looking at the demographics - the average distance was around 600 km’s so it just gives you an idea of where these people are coming from. I have worked in the burns unit before and I can easily recall patients coming in for very brief appointments, after hearing their stories of about one or two days travel, just to come in. And these are appointments happen every three months, six months, 12 months. So, average distance, 600. So, what I did I kind of multiplied that out by the number of cases per area, and it came up to 2.8 million km’s. Which is quite a lot of savings. Even more, just to put that into context, so that people know, that is four return journeys from earth to the moon.

So, we have been doing work in diabetes as well, in a range of different areas. We provide patient education, support for paediatricians and support for a range of different allied health therapists to our patients with diabetes, general surgery, burns care is one example, but that has opened up a whole range of different areas including ears, nose and throat, vascular surgery, orthopaedics and general surgery. The general surgery is quite interesting, because all the pre-op appointments, we are trying to get as many of them, certainly outside of Brisbane, to come in and have a video conference. And that is working extremely well. You can see a bit of a shift back in 2010, 2011, on the chart there and that is because we brought out a new coordination model and we set up different regulations for clinics for all of our doctors and that model is working extremely well. That has basically changed from 19 consults to about 160 consults per year for our general surgery teams and we have written a number of papers on that.

Home support. Some of our work is trying to get patients out of hospitals and into their homes, and this is working very well. We are talking about a very small cohort of patients, particularly our palliative care group. We try to get them out of our oncology units and medical units into the home, where they much more comfortable, with mum and dad and the kids and the pets, aunts and uncles, everything else that comes with that. But, most important thing, they are in a comfortable environment. We use a range of different techniques, about 10 years ago, when we started doing this work, it was hard to find a family that had a computer or internet. Now most of our families in these locations have four or five computers and a very good internet connection. Probably better than the one I have in Brisbane. So, it is improving. It is a dynamic field, Telemedicine, because the actual infrastructure that we have available to us, is improving all the time. 

We actually brought clown doctors out by Telemedicine as well and wrote a paper, and this is one of the first in the world kind of. So, if the patients at this busy hospital, do clown doctoring, why can’t our country patients get it as well. So, the clown doctors come in and they do their entertainment and they wrap our video conferencing systems up in toilet paper and they do a whole range of things. Their job is to really entertain the kids, no matter where they are, whether they are in the hospital or they are out in our remote locations. The other area I wanted to tell you quickly about it, was our robots, which began in 2004. We don’t use our robots anymore, but it did demonstrate a very important point. The robots were designed to support a remote hospital that had no paediatrician and what we decided to build something that was not only child-friendly but also could be taken to the bedside. This is the idea about wireless, mobile video conferencing. Keep it very simple. So, what we did is, we designed with fibreglass, kind of a robot casing. The video conferencing system was inside this and there was nothing else special about it. It has some wireless networking, it is really, really simple. These robots were operated from Brisbane. So, we could turn them on and off. All that had to happen at the other end was the nurse or doctor just wheeled it to the bedside and then the doctor would appear on the screen. They could do the consult, so we did ward rounds twice a day with the paediatrician. The ward that we focused on had no paediatrician, despite a ward full of kids, that needed one. And we were able to link up junior doctors and nurses and monitor them twice a day. We built a few robots in our time, to try different models and techniques. Now the Queensland health system operate a very nice clinical system, as one of their standard products in their line.

I haven’t come across this complaint yet. So, ears, nose and throat is quite interesting as well. What can we do with kids who have ear problems? Again, it’s a typical problem, kids come down with their suitcase and their toothbrush, they see an ear, nose and throat surgeon and yes, you need a tonsillectomy and mum and dad are excited, we’ll send you a letter for your operating room appointment. They thought it was going to happen, there and then, didn’t they? So, no, that’s not the case. What we are doing is, pre-assessment again, so we are using a video endoscope, with a nurse that is trained at the other end. Ear, nose and throat surgeons and doctors and their teams will look at these cases and discuss the case with their paediatrician, talk to Mum and Dad, talk to the kids involved. If surgery is required, they are put onto the list and that at least saves one appointment. Much of the follow up is also being done by video conference, so a simple grommet check-up can take about 90 seconds. So, if I am travelling a long distance for a 90 second appointment after having waiting an hour and half in outpatients, I wouldn’t be too impressed. Just to - for those who haven’t seen the type of images that you can get, this is just - ignore the background noise - this is looking inside the ear drum, inside the ear, so looking at an ear. If you want to look at the ear, eyes and nose and also in the mouth. So, these are videos can be pre-recorded or shared live by video conference. The idea of collecting these images gave me another idea, back in 2004 when I visited an Aboriginal community called Cherbourg. Cherbourg is a small Aboriginal of about 1000 kids. Very high prevalence of ear disease, anecdotally about 90% of the kids in the community have ear disease. The World Health Organisation say about 40-42% is classified as epidemic, so something wasn’t quite right. So, what we did is we took the system out to the remote community, set an outpatients. This is just a testing phase. We got all the kids to come up and have a look at their ears. All of a sudden, things changed. If you think about it from the perspective of a patient, it doesn’t matter if you are of Indigenous background or not. All of a sudden, visualising or seeing inside your ears or inside your throat or looking at a condition makes a huge difference. People, all of a sudden, started to take ownership. So, instead of hearing a fancy diagnosis from a clever ear, nose and throat surgeon, all of a sudden we could see the problem on the screen. And that was a very interesting kind of development. In the bottom left hand corner, were a group of kids looking in their ears. That was quite entertaining. Some of the things they said to me whilst I was doing it was very entertaining, got a few surprises along the way, but most of importantly they kind of thought this was pretty cool. We could do this. So, we had an idea. Rather than us do this work, why don’t we get the Indigenous community to do the work themselves and we just support them. So, we built a mobile clinic. A mobile hospital which had everything inside it to do all the screening. So, a videodiscope, computers to store all the images, an SG connection, a database that we built. So, the information is collected by the Indigenous worker, who is in the bottom left hand corner, his name is Pickle. He’s famous, I think he is famous. He’s one that runs this program, not us. We are the invisible people behind the scenes who provide all the support. But it is his service. And Cherbourg know him as the one running the service. Beautifully accepted by the community. You open it up with all the traditional processes and we had the elders give a couple of talks about their stories and how important this was. So, it was a very good demonstration of community acceptance. All of these images are collected, they are viewed by an ear, nose and throat surgeon in Brisbane, usually once a month and then all the information is used to support an outreach program, where now our team go out and do surgery out in that community. So, very high community acceptance was demonstrated by our consent rate. When I began this program back in 2008, we received funding for the vehicle and we got the green light to start. Our big pressure point, really was - was the community going to consent to it. I knew that they were positive and on board. We had almost 100% consent rates. We had teachers going to doors, door knocking. We had people going down the road to the park, getting people to sign forms. We didn’t have to do any of that, the community did it, because they wanted it. This vehicle goes around to 32 schools in the area now, mainly in Cherbourg, but also in peripheral schools. Screening rates have increased, waiting times have increased – that’s a bad thing – has gone down. Interestingly the movement of patients as you would expect has also changed. So, there are less children having to travel to Brisbane and more services being provided in the community. Let me show you that. So, before we started the program, there were about just under 40% of the kids being screened. I remember, anecdotally about 8 or 9 out of 10 kids had some type of ear disease. We have improved screening rates to over 85% and that has been consistent since the program started. The waiting time we have changed from about 73 days to around a month. Now this is very interesting, because the policy according to the Brisbane Hospital was about 34 days. So, I was breaking the rules. But anyway they are getting an excellent service and it is on par with what we are getting in the city environment.

The other very interesting thing, as you would expect, is that the delivery of surgical procedures has certainly shifted in favour of the group in Cherbourg and this is a much better model. I remember having the discussion with the district manager once, who said to me, "look, have a look at this waiting list for operating theatre," and the failure to attend rate was normally 100%, you know 12 kids, 100% failed to attend. That costs money, it costs resources, it’s inconvenient. But also think of it from that patient’s perspective, they are not getting the service they need, because they couldn’t physically get down. So, this team now travel out to Cherbourg and do most of the surgeries out in Cherbourg that are deemed safe to do. So, activity to date is encouraging. We’ve got children who are being registered into the program all the time. Our screening rates are being maintained and our assessments are steadily increasing. 

So, another project is called Healthy Regions, which takes a different approach to doing Telemedicine and this is an approach that is taken out to the community to look at the whole community approach. And it is a program that I had funded by QDC who wanted us to focus on three particular towns that they were working in: Dolby, Chinchilla and Miles. And what makes this program particularly interesting is that, my focus wasn’t just on the hospital system, it was on a whole range of different systems and think it is an important thing with Telemedicine, is that you just don’t go in with one sided, that you are going to provide a hospital to hospital service. It’s about engagement and links with general practice, with Aboriginal medical centres, with schools and with hospitals. It’s complex. You are dealing with lots of different people, different personalities, different systems, different responsibilities but our focus in this area, although it is a relatively slow one in the scheme of things, is try to bring all of that together and improve the communication that happens between all of those service providers. So, we’ve run a number of community events. We’ve run launches in each of these areas to make people aware of Telehealth. We have done letterbox drops, interviews with the general public. We interviewed about 60 patients, through interviews, you know, so if you ever heard some strange looking guy, chasing some in the shopping centre in Dolby, that was me. But the interviews were done for a good reason. We have just also written up a paper, which is under review at the moment, looking at understanding and perceptions of Telemedicine. And, as you may expect, patients knew very, very little about Telemedicine. They just didn’t know. And I think that is another very important area that we need to look at, public awareness. So, we’ve got a campaign which is called Ask for Telehealth. Now this is a cautious campaign because I think that one of things we need to be careful about, is not to have a big tsunami of people running into general practice and hospitals looking for Telemedicine. If the Telemedicine isn’t there. Otherwise it is going to cause a lot of disappointment from the patient perspective. It is going to cause a lot of angst and irritation from the service provider if they don’t have Telemedicine. So I think it is a balancing act. So we are focusing on the service providers. We’re feeding information to the general public, and trying to bring it together on balance. And it is a bit of a juggling act.

So, I just wanted to run through very quickly an example of a study that we did, which is a cost and minimisation study. And I don’t want to go through a health economics lesson, that’s not the point of this. But it is important for us to be looking at our Telemedicine services from an economic angle. And economics can be looked at from a range of different perspectives. You can look at it from the perspective of the health service provider. You can look at it from the patient perspective, which is a common one. But also more broadly from society’s perspective. You know, what does it cost for us to invest in this and what are the potential savings, if there are any. So this is an example of our child psychiatry run over a 30 month period. And I compared the cost of providing these services done by Telemedicine. The services provided during outreach, where the person travelled to the site and also the costs if the patient travelled down to Brisbane. And putting all of those costs, the fixed and variable costs into there, you are able to work out what the average cost is. But the marginal cost is the one that we are particularly interested in. So the marginal cost is assuming, the infrastructure is in place and this is what it would cost to do an appointment. So the face to face, owing mainly to the cost of travel was about $1000. And out Telemedicine option was about $190. So, a reasonable difference. Once you have that information, then it’s also important to try to plot it and to try and work out where your threshold point or where your breaking even point is. And the breakeven is determined on volume of work. So, if you are planning a Telemedicine operation that would have relatively low volume, then you may want to consider what it costs to establish, over the costs of the savings. So, in our case, we were easily breaking even. So, our threshold point was on a different plane. But the important thing here was, if our activity had exceeded our savings would have been greater. If our activities had been about 100 consults, we would have been looking at maybe a visiting outreach program, instead of Telemedicine. 

So, just overall, the Tele-paediatric service there, the coordination there behind the scenes is very, very important. It’s been a very important driver for the work that we have been doing over the last 15 years. It’s an important model that supports everybody involved and it’s not just the clinicians, but it is also the people involved from the appointment end, with our patients and our parents. It is one of the largest reported services of its kind, in terms of the breadth of services offered and, most importantly, it is demonstrating a way of trying to improve equity of access to services. 

So, I want to take a jump from paediatrics and child health into the adult arena, just briefly, and in 2012, we had an opportunity to work with the PA hospital to look at adult services and the idea there was to try and replicate what we had done in paediatrics and try and move that into an adult environment. This is generally the model and we use this model for a range of different services but it just illustrates that this is the functionality of the centre that we have constructed. It’s not just about providing reception services and helping people with Telemedicine. But you will see on the left hand side there under ‘service establishment’, there are a lot of things that you to focus on when you are trying to build or grow a Telemedicine operation. There is working with the clinicians, there is change management, looking at decision support systems, electronic records. There is a whole lot of work that needs to be done with these people. So, we’re working with a number of different groups, and most importantly, the PA Telehealth centre is distributing services, not only at the hospitals but now into Aboriginal medical services and also into general practice. 

The thing I like the most, in contrast to our work at The Children’s where we started in a concrete slab, there was two or three of us in the centre at The Royal Children’s with a jar of Nescafe, we have grown that obviously, but with the PA we had an opportunity which you don’t get very often and that was ‘design your own,’ you know, what do you want to do with your space. So, the CEO of the hospital carved off a section of the library which was under used and we had some space to work with. So, this was our floor plan we wanted some dedicated studios. We wanted a very nice reception area, where coordinators could work and monitor the work, like a bit of a docking station. We wanted space for our researchers and academics who are looking at innovation, working with clinicians and reasonable office space for meetings. So, just to, because I can’t all walk you through the centre at the moment, if you are in Brisbane everyone, I am more than happy to give you a tour. But that’s our front reception. You will walk through. A view from our coordination station there, you’ve got these consult rooms that are all set up. We have got some meeting rooms with standard video conferencing. This is an example of our consult rooms. So, every consult room is set up in exactly the same way. A couple of the rooms have a couple of different pieces of equipment, depending on the specialties, but the idea is especially if you go into a consult room, 1, 2, 3, 4, 5 or 6, you are going to be sitting in very similar environment and you are going to know where everything is. The other important thing is the screens on the desks, they act as a bit of a console, we call it our cockpit. So, all the electronic records and the information that people may want, sits in that screen. It needs to accessible, very easy for the clinicians. From the viewing perspective, when you are the patient, you don’t see any of those screens, they are just out of view. So, all you will is the consultant’s face. In terms of just activity, just to share with you in the last three years, the activity is increasing steadily. I also said that this would take about five years before we would realise the activity increasing. Our centre itself has capacity to do around 8000 consults per year. But we are years away from doing that, because there is so many processes to get right, before we are able to reach that volume. So, there is a number of specialities. Geriatrics is dominating the group. But there are lots of other specialities which I haven’t shown on the list here that we are currently working with and developing business cases and talking to the clinicians about what they can achieve. So, another example of the work, which is slightly linked to the PA is your Tele-geriatrics. My director, Professor Len Grey, is one of the leads in this program of Resicare. He and I helped develop this model about four years ago and it has now moved into a commercial business run by Uniquest. The idea here is to provide Telemedicine services into residential aged care facilities on a routine basis. So, we call that an academic Telehealth service because we are always embedding research and evaluation into it to see what works and what doesn’t. It is operated jointly by the Centre for Online Health and also by the Centre of Research and Geriatric Medicine. So this works in such a way that we have a complex or comprehensive geriatric assessment. These assessments are done in advance, they are done by the nurse caring for the patient. These are available online and are used by the geriatrician. We try to set these up in such a way that we have weekly clinics available to each of the RECF’s and they book their new cases in and also review cases. So, the structured assessments processes, the intertied software, which is put into the online version of CGA which is something that we have also built. The work that we are doing is not just geriatric support, the idea is to get the geriatric support working really well, and humming along, before we start bringing in other sub-specialities. So, the model is, bring in other geriatric services where it is much needing in nursing homes. Once we get economies to scale and once we develop the number of sites that we have available, then you can bring some other sub-specialities into play. This is just an example of Len on the TV screen and a patient in the bed. There are a number of ways that we do, do this. We use mobile video conferencing, but we also use room based systems, depending on what the facilities prefer and depending on what infrastructure is available. And, from the perspective here, looking at the screens, similar process to having the monitors available for the video conferencing. Very interesting that this just demonstrates that the importance of having records, apart from the fact that our doctors usually carry around half a dozen passwords, which I think is unfortunate and really a problem that we have. I also give them access to the internet, and that has proven quite useful. Interestingly, when you are a looking at gait or physical movement of a patient, getting on to google street view, you can start asking questions about their steep stairs at the front of the house. And you get this puzzled look on their face. Like ‘how did you know?’. So, the Resicare model is about supporting residential aged care facilities and sites that normally don’t have access to specialist geriatric services. It is certainly supporting skilled development. So engaging nurses and doctors with each other certainly has its benefits. We’re doing a study at the moment, so it’s easy for me to stand up and say this is fantastic but we have a randomised control trial at the moment, funded by NHRMC to look at exactly that, to look at the clinical outcomes and the benefits and this study is underway and the intervention stage or recruitment stage finishes towards the end of next year. 

So, I’ve given you a fair bit of information to digest on a number of the services. One of things I wanted to share with you too, our role in the Australasian Telehealth society, my role as the President and Tory as the Vice President is to really to provide an opportunity to provide or a society for people to collect information or access information. My feeling, nationally and internationally, is that there is so much really good information out there, it’s just where do you start? You know you can ring a certain person or email them but we’re trying to set up a repository or a single point where people can get that information and share and engage. So it is about getting together and sharing that community and I encourage people to be part of the society. There is a website there where you can get information. But we are interested in getting everybody’s experiences and there is excellent work, as we discover, happening in every state and territory around Australian and also in New Zealand, which we partner with. So, certainly get involved, if you have a look at the website, join the mailing list. The other important tip I will give you is we’ve got our conference coming up, which I will show you little bit later on. If you come along to the conference, you get free membership, so don’t sign up yet. Come along to the conference and we are going to get you free… (laughter) no, you get membership. 

So, just back on to the actual process of doing Telemedicine is that doing Telemedicine, as I said before, is not about putting in boxes and wires and expecting it to work. You know, Telehealth is a much more engaging process, where we are looking at change management, working with people, trying to understand how we change old, conventional models to new models that perhaps are more efficient. So, it’s really important that we kind of sit together and try and work out what the best model is, you know, we have got face to face, we’ve got outreach, video conferencing, you know, what is the most suitable model? And what don’t be scared about change. Another important point is that you need organisational support and I certainly get that strong feeling here in Victoria. We have it in QLD but having organisational support, if you don’t have that, it makes life very difficult. Very, very difficult. And the support, mind you, is just not top level support, it is also clinician-driven support. You need the clinicians on board and want them to feel empowered and responsible for doing that. So, there are plenty of changes happening in our environment you know, in telecommunications, and that and people need the change the way that they work. So, this is not an exhaustive list. This isn’t everything you need to know about Telemedicine and what you are required to do Telemedicine well, but, there are a whole range of things that we tend to have to go through our checklist and I will share a couple of those things with you. You know, clinical resourcing, you know it is a great idea to do Telemedicine, but if you don’t have the staff it makes it really hard to do. Is this a case of providing a new service or implementing a new service or complimenting or substituting a service. So they’re the things that we need to think about. Looking at secure funding. Traditionally, Telemedicine has been blamed for picking up lots of small projects and a bit of a job about pilots for Tory Wade, more pilots for Telemedicine than Qantas. But I think it is really important that we now are seeing funding models emerging in Australia that are actually supporting Telemedicine. So, that is a very positive sign. Getting referral pathways very clear and understanding who does what. And how do you actually generate a referral is very important. Looking at hosting services. Telemedicine, by its very nature, because it involves more than one site, all of a sudden requires people at both ends. So, you can’t forget about the other end when you are doing Telemedicine. It does impose time requirements and you do need to develop skills and training for people at the other end. Looking at the scope, what can you do and what can’t do is very important to identify. Incentivising, we have seen a number of different financial incentives put into place but also the method of operation is also very important. So, engaging from remote sites, no point it being in a nice big city hospital, saying we are going to do Telemedicine. You are going to have it, whether you like it or not. That doesn’t really work. You need to engage with those groups. Another specific check list is this one here, so I mentioned funding before, it’s very, very important and there is some funding that’s now available, obviously through the Medicare system - Telehealth items, that was introduced back in 2011. But the other very important responsibility that we have when we are developing Telemedicine, this is what the Centre for Online Health enjoys doing in a clinical environment, is that you get to engage with clinicians and understand exactly what they want. So, take a step back, take a breath and think, what are we trying to achieve here, what are the clinical requirements, what are you trying to do and what are the processes? I think Telemedicine, with the change management, is all about reengineering. So, we’re taking an old hospital system or a health system which can’t keep up with innovation. We’ve got new funding methods that are being brought in, we’re ahead here but we’re being dragged along by the system. So we have got to try and change that and influence that. I’ve talked about incentives. You need clinician support and the big one there, that I am not going to answer in the time that I have left is electronic records. This is a real challenge. Making sure we can share records, document efficiently and make sure that we’ve got the information available to do our consultations efficiently.

This is a slide taken from a paper published just last year by Tory and her team. Just looking at Medicare. So, uptake is steadily increasing, as you see there, in the scheme of things, relatively small. From a Federal Government perspective, I think Telemedicine accounts for less than 0.02% of all activity currently, so if you compare that to face to face. I did a study a number of years ago that looked at tele-psychiatry and if you compared face to face, appointments to the Telemedicine it was about 0.02%. So, very small in the scheme of things. I am not saying that to be negative because in time, this illustrates that in time there is a steady increase in the uptake of Telemedicine in Australia and that’s encouraging. So, a couple of practical tips to, kind of finish off. Develop your systems, develop your Telehealth systems systematically. Start small and gradually develop. Don’t get in there with this huge ‘I’m going build Victoria or build Queensland and I am going to do it by Sunday afternoon’. It just doesn’t happen. Don’t forget about the clinician’s and the patients. You know, make sure there is very good engagement between them. You may be an expert in Telemedicine but there is a lot of different aspects that need to be played out. I encourage you, when the opportunity arises, and we’re certainly happy to assist with this, but take the opportunity to report your work, all the good things that you are doing. From my own personal perspective, you know you are always astonished when you hear of different programs happening that you have never heard about or you have never read about. Its only when you bump into someone and say ‘look, I’ve being doing this for five years’ and you think it is brilliant and if you can, please try to write it up and try to get it in a report or on a website or in a publication. There a number of different areas that I encourage you to look at, from an evaluation perspective, and they’re listed there and if you are relatively new to the field, have a look around. So read papers or look at websites, you know, talk to us about what’s been done and what’s worked. Try to make your move, based on those services that have succeeded, rather than those that have failed. I have come across many different examples where someone has said that ‘I’ve done this, I’ve just spend $1.2 million dollars, you know we thought the patients would love it but it was an absolute disaster.’ And you think ‘well quite a few people have done the exactly that and reported that it has been a disaster.’ So have a look at the reports and learn from other’s experience. We run a meeting called Successes and Failures in Telehealth, which I will say, as a day claimer, is coming up in November in Brisbane. We have been running these for 15 years. And what I do is, I purposely get people to get up on the lecture and many people today here have actually done that very well, to talk about successes or failures or a bit of both, in Telehealth. It is always good to get up and talk about the "F" word. You know people often want to get up and talk about successes and look how great we are, but it is also really important to get up here and talk about those things that we thought were going to work but just didn’t go our way. And that’s what really, I think, will help propel and assist with the development of Telemedicine. 

So, just in conclusion, conventional models of health care are really not sustainable We need to change and change is inevitable. We kind of need to look at our practices and Telemedicine or Telehealth, in its own right, is a disruptive technique. It’s about changing. We are going to be forced to change the way we work in order to be able to deliver the services that we have to in the very near future. So, very importantly, it’s not just a single lined approach, you have got to look at it from a whole of system approach, in order to develop your successful uptake of Telemedicine. So, ultimately, to finish up on this point here is, you know, a key driver, why are we here? We are here to try and give our patients the absolute best access to specialist services as we can, irrespective of where they happen to live. And that goes for Queensland, that goes for Victoria, it goes for every state and every state in the world. Thank you.