Dr Anthony Smith Deputy Director and Associate Professor at the Centre for Online Health, The University of Queensland, Australia Executive Committee Member for the Australasian Telehealth Society

1. Telehealth in Australia:
Emerging Trends and Challenges
Dr Anthony Smith, Associate Professor
Deputy Director
Centre for Online Health

2. Acknowledgements
 HIHNZ and the National Health IT Board, NZ
 Pat Kerr, Roy Davidson and Terri Hawke
 Centre for Online Health, UQ
 Prof Len Gray, Dr Nigel Armfield and colleagues
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

3. Centre for Online Health
 Broad interest and experience in telehealth
 New models  Evaluation
 Service delivery  Teaching and consultancy
 Queensland Telepaediatric Service >12y
 Adult/geriatric telehealth services
 SFT Conference
 www.uq.edu.au/coh
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

4. Mud-map (Overview)
 Australia in context
 Examples of telemedicine in Queensland
 Measuring outcomes
 Government investment –Medicare and the NBN
 Success factors
 Collaboration
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

6. Australia
 Population 22m
 One third of the population live outside major cities
 Indigenous population – approx. 520k
 Most specialist services – centralised, major cities
 Transport requirements significant
 Equity of access issues
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

7. Current practice and research
 Contemporary use of telehealth, on the whole is:
 Focused on specialist consultation to patients in rural and
remote locations
 Used in selected specialties least compromised by the
limitations of VC
 Hardware video-conferencing based (good quality but $$$)
 Mostly hospital based
To date there is little research around the use of
telehealth in primary care…
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

8. Key issues in Queensland
 Extensive distances and location of specialist health
services
 Equity of access to health services for regional and
remote population
 Large videoconference networks
… but relatively slow uptake
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

10. Logistical challenges
 Incorporating telehealth into mainstream practice
 Complimentary method of consultation
 Existing referral pathways – or new?
 The complete picture – FTF, outreach, telehealth
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

11. Telehealth coordination
 INCENTIVE
 Single point of contact
 Manages referral
 Liaises with specialists
 Schedules appointment
 Facilitates medical records
 Manages videoconference session
 Collects activity data
 Organises follow-up if required
Smith AC, Isles A, McCrossin R, Van der Westhuyzen J, Williams M, Woollett H and Wootton R. The point of referral
barrier - a factor in the success of telehealth. Journal of Telemedicine and Telecare 2001; 7 (Suppl.2): 75-78

12. Telepaediatrics in Queensland
General
paediatrics
Sub-
Home
Specialist
telehealth
referrals
Telepaediatrics
Indigenous
health Critical care
screening
Neonatal
intensive
care

13. Telepaediatrics in Queensland
Neurology
(n = 11,250 consultations)
10%
Burns
14% ENT
7%
General Paediatrics
5%
Endocrinology
5%
Child Psychiatry Oncology
27% 3%
Nephrology
3%
Orthopaedics
2%
Cardiology
2%
Ophthalmology
Other 2%
18% Dermatology
2%
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

14. Telepaediatrics in Queensland
 14,350 consultations over 12 years
 2400 consultations per y
2800
2400
Consultations
2000
1600
1200
800
400
0
2000 2002 2004 2006 2008 2010 2012
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

17. Telepaediatrics - ENT
 2 years – 152 consultations (97 pts)
 Retrospective audit of medical notes
 Diagnosis – 99%
 Management – 93%
Smith AC, Dowthwaite S, Agnew J and Wootton R. Concordance between real-time telemedicine assessments and
face-to-face consultations in paediatric otolaryngology. The Medical Journal of Australia. 2008, 188 (8): 457-460
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

18. Indigenous health screening
~90% significant disease/deafness rate
Long-term impact:
 1-3y; severe disease burden (discomfort)
 4-5y; slow language
 5-7y; slow learning
 10-11y; behaviour problems, truancy
 15y; illiteracy, substance abuse
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

19. Indigenous health screening
 Indigenous health workers
 Specialist outreach services and telehealth support
 ENT
 Dental
 Dermatology
 Ophthalmology
 Psychiatry
 Respiratory
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

21. Telepaediatrics - Burns
 Compare FTF to VC assessments
 12 months – 25 patients
 1.One observer, alternating process FTF/VC - VC/FTF
 2. Two observers, FTF consults
Smith AC, Kimble R, Bailey D, Mill J, and Wootton R. Diagnostic accuracy of and patient satisfaction with telemedicine for the follow-up of
paediatric burns patients. Journal of Telemedicine and Telecare 2004, 10(4):193-198
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

22. Telepaediatrics - Burns
FTF FTF / VC
Consultant A Concordance % Concordance %
Consultant B n=25 n=25
Appearance 68 60
Scar thickening 60 64
Contractures 92 92
Range of motion 92 92
Activity level 100 100
Breakdowns 96 96
Decision making 100 100
Smith AC, Kimble R, Bailey D, Mill J, and Wootton R. Diagnostic accuracy of and patient satisfaction with telemedicine for the follow-up of
paediatric burns patients. Journal of Telemedicine and Telecare 2004, 10(4):193-198
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

23. Telepaediatrics - Burns
 ~ 17% of all burns outpatients
FTF appointments Telepaediatrics
2100
1800
1500
Consultations
1200
900
600
300
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

24. Telepaediatrics - Surgery
 Rapidly expanding
 Routine clinics with all paediatric surgeons
 6 clinics per month, up to 2 hours each
 multi-site appointments
 Pre-admission, reviews and education
 Referrals:
 Direct to QTS via 1800 number
 Patients triaged at the RCH OPD according to postcode
 Appointments held at nearest regional hospital
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

25. Telepaediatrics – Home support
 Video links to families at home
 Palliative care, oncology
 Support from medical, nursing and allied health staff
 Logitech video – via broadband connection
 Laptops and PCs - flexible
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

26. Telepaediatrics – Robots
 Telepaediatric robots
 Commenced 2004
 mobile, wireless videoconference systems
 child-friendly
 direct to bedside
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

27. Telepaediatrics – Robots
 2005 – Gladstone Hospital, no paediatrician
 daily ward rounds
 sub-specialist consultations
Smith AC, Coulthard M, Clark R, Armfield N, Taylor S, Goffe R, Mottarelly I, Youngberry K, Isles A and Wootton R.
Wireless telemedicine for the delivery of specialist paediatric services to the bedside. Journal of Telemedicine and
Telecare 2005, 11 (Suppl. 2): 81-5

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

30. Neonatal ward rounds
Often full care team attend
 Medical
 Nursing
 Allied Health
 Social work
Mackay Base Hospital ICN, Townsville Hospital
Round led by neonatologist
Family members may participate
Usually informal educational opportunities
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

34. Outcomes
 User satisfaction
 Changes in clinical practice
 Accuracy
 Patient outcomes
 Education and training (workforce development)
 Economics
CRICOS Provider No 00025B
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

35. Cost minimisation analysis
 Child and adolescent psychiatry services
 e-CYMHS
 30 month period
 Costs of providing telepaediatrics - video
 Costs of providing outreach – visiting psychiatrist
 Potential costs if patients travel to the RCH
Smith AC, Stathis S, Randell A, Best D, Ryan V, Bergwever E, Keegan F, Fraser E, Scuffham P and Wootton R.
A cost-minimisation analysis of a telepaediatric mental health service for patients in rural and remote Queensland.
Journal of Telemedicine and Telecare, 2007, 13 (Suppl. 3): 79-83
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

36. Telepsychiatry
30 months – 606 consultations
Method FTF – Patient FTF Outreach – Telemedicine – Patient
travel ($) Visiting seen via
Psychiatrist ($) videoconference ($)
Total cost 514,094 299,913 230,753
Average 1073.25 494.91 380.78
Marginal 1073.25 494.91 190.01
Smith AC, Stathis S, Randell A, Best D, Ryan V, Bergwever E, Keegan F, Fraser E, Scuffham P and Wootton R.
A cost-minimisation analysis of a telepaediatric mental health service for patients in rural and remote Queensland.
Journal of Telemedicine and Telecare, 2007, 13 (Suppl. 3): 79-83
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

37. Telepsychiatry (30 months)
Actual
800,000 Patient
travel
Cost ($)
Visiting
400,000
Psychiatrist
Telemedicine
0
0 100 200 300 400 500 600 700
Consultations
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

38. Developments in Australia
 Medicare items for online consultations recently
introduced in July 2011
General practice
Broad range of health specialties
Focus on video consultations
 $620m+ invested by Commonwealth Government
Financial incentives – 1st consultation, loadings
Funding for training, support
Promising sign for telehealth in Australia...
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

39. Telehealth uptake
 New MBS telehealth items - what is the prognosis?
 Likely uptake, long-term trends?
 Learn from experience (successes and failures)
 Telepsychiatry in Australia*
Commonly reported, telehealth friendly
MBS items for telepsychiatry - introduced early 2003
* Smith AC, Armfield NR, Croll J and LC Gray. Medicare. Journal of Telemedicine and Telecare, 2012, in press
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

40. Methods
 Review of MBS activity* for psychiatry services
Reports via Medicare Australia*
July 2002 – June 2011
FTF and VC items compared
 Activity reports included:
Services delivered – number of consultations
Benefits paid – Medicare costs
* http://www.medicareaustralia.gov.au/statistics/mbs_item.shtml
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

41. Telepsychiatry MBS items
 MBS items (for VC) introduced in 2003
Consult time FTF VC
<15 min 300 353
>15 min and < 30 min 302 355
>30 min and < 45 min 304 356
>45 min and < 75 min 306 357
>75 min 308 358
Ref: http://www.medicareaustralia.gov.au/statistics/mbs_item.shtml
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

42. Telepsychiatry MBS items
 Registered services (July 2002 – June 2011)
Consult time FTF VC
<15 min 300 371,501 353 1644
>15 min and < 30 min 302 2,372,696 355 2710
>30 min and < 45 min 304 4,319,122 356 1623
>45 min and < 75 min 306 6,389,628 357 1966
>75 min 308 358,386 358 60
Total 13,811,333 8003
Ref: http://www.medicareaustralia.gov.au/statistics/mbs_item.shtml
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

43. Telepsychiatry MBS items
 Benefits paid (July 2002 – June 2011)
Consult time FTF VC
<15 min 300 $12,501,152 353 $73,611
>15 min and < 30 min 302 $158,144,708 355 $246,630
>30 min and < 45 min 304 $440,522,059 356 $221,258
>45 min and < 75 min 306 $941,480,922 357 $380,118
>75 min 308 $59,479,219 358 $12,873
Total $1,612,128,061 $934,489
Ref: http://www.medicareaustralia.gov.au/statistics/mbs_item.shtml
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

44. Results
 Benefits paid (July 2002 – June 2011)
Total MBS Expenditure VC related services (%)
$200,000,000 1
$190,000,000
Total MBS costs ($)
Proportion (%)
$180,000,000
$170,000,000
$160,000,000
$150,000,000 0
2002/2003 2003/2004 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009 2009/2010 2010/2011
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

45. Summary
 MBS Activity (July 2002 – June 2011)
 14 million services (psychiatry consultations)
 $1.6 billion MBS funded psychiatry services
FTF VC %
Services 13,811,333 8003 0.06
Benefits $1,612,128,061 $934,489 0.06
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

46. Findings
 Despite item numbers being available for
telepsychiatry since 2003, uptake has been very slow
 Considering reported telehealth success in psychiatry
– results may be surprising?
 Telehealth success factors
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

47. National Broadband Network (NBN)
 Construction from 2009 (10 year plan) – NBN Co.
 Replacing existing copper network
 High speed broadband for all Australian households
 Government investment – approx. $37b
 Fibre, wireless and satellite
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

48. National Broadband Network (NBN)
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

49. National Broadband Network (NBN)
 97% coverage, satellites for the remainder
 Healthcare?
 Telehealth – not NBN dependent, but…
 Opportunities to develop new methods
 Increased reliability, transmission speed
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

50. Critical factors
 Funding
 Clinical services (clinicians)
 Infrastructure, equip and telecommunications
 Administrative and clinical systems
Smith AC and Gray LC. Telemedicine across the ages. The Medical Journal of Australia. 2009, 190 (1): 15-19
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

51. Telehealth checklist
 Funding
 Careful design – clinical requirements
 Organisational support – willingness to change
 Re-engineering conventional referral processes
 Complementary (with outreach, patient travel)
 Incentives – comparable (or better) than FTF
 Clinician support (near and far)
 Electronic records
Smith AC and Gray LC. Telemedicine across the ages. The Medical Journal of Australia. 2009, 190 (1): 15-19
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

52. Change management
 Telehealth implies a change in practice
 Rethinking how services are delivered (e.g. specialists
consultations face-to-face vs. online)
 This may take considerable time and the results are
unpredictable
 Needs organisational support for success – across a
wide range of settings
Gray L, Smith AC, Armfield NR, Travers C, Croll P, Caffery L. Assessment of telehealth implementations and associated
requirements (2010). Department of Health and Ageing, Australian Government. Reports available via the MBS Online
website: Telehealth Business Case Advice and Options and Telehealth Assessment Report
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

53. Practical tips
 Develop new services systematically
 Start small and gradually develop
 New applications:
 Feasibility, technical, user satisfaction
 Clinical efficacy – comparable to FTF
 Economic evaluation – patient, health service, society
 Learn from experience – successes and failures
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

54. Collaboration
 Established in 2008
 Bringing together a community which is currently
fragmented and does not have a single forum for
sharing of issues.
 Researchers, telehealth practitioners, clinicians,
managers and industry partners together in a unique
interdisciplinary grouping.
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

55. Australasian Telehealth Society (ATHS)
 Membership – individual and corporate
 www.aths.org.au

56. Australasian Telehealth Society (ATHS)
 Executive
 President – Prof Anthony Maeder (NSW)
 Vice President – Jackie Plunkett, NT
 Secretary – Laurie Wilson (NSW)
 Treasurer – Prof Colin Carati (SA)
 Committee
 Dr David Allen, Telehealth Solutions (NSW)
 Mr Simon Hayden, Vivid Solutions (NZ)
 Prof Yogesan (Yogi) Kanagasingam, CSIRO (WA)
 Ms Pat Kerr, New Zealand Telehealth Forum (NZ)
 Dr George Margelis, Care Innovations (NSW)
 A/Prof Anthony Smith, The University of Queensland (QLD)
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

57. Call for Papers
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

58. Global Telehealth
 Call for papers -
 Submission of Full and Short Papers: Friday 28 July 2012
 Notification of acceptance to authors: Friday 25 August 2012
 Camera-ready copy for proceedings: Friday 8 September 2012
 Author & Early-bird registration deadline: Friday 8 September 2012
WEBSITE: www.aths.org.au/GT2012/
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

59. ???
“That it will ever come into general use,
notwithstanding its value, is extremely doubtful
because its beneficial application requires much
time and gives a good bit of trouble, both to the
patient and the practitioner.”
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

60. ???
“That it will ever come into general use,
notwithstanding its value, is extremely doubtful
because its beneficial application requires much
time and gives a good bit of trouble, both to the
patient and the practitioner.”
1834, London Times
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

61. Conclusions
 Commonwealth (Medicare) funding for telehealth is
welcomed in Australia, but long-term strategies need
to be adopted to ensure steady uptake
 A whole of system approach is essential for the
successful integration of telehealth
 Telehealth requires health services to be re-
engineered to maximise the opportunities – change is
required
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

62. Shared vision
Ensure all patients are able to access the
highest quality health services in the most
efficient manner regardless of location
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia

63. Dr Anthony Smith
Associate Professor
Deputy Director
Centre for Online Health
Email: asmith@uq.edu.au
Web: www.uq.edu.au/coh
Associate Professor Anthony Smith
Centre for Online Health, The University of Queensland, Australia