The NBN and Healthcare

Image of a doctor smiling in front of a computer screen.

Even though the ALP version of the NBN has been consigned to the same parts of the history books as the ALP itself for now, some of the journalism around the NBN still doesn't come from a completely dispassionate standpoint.  I'm more zen about that than some others, I think bad journalism is more about a ratio of expected to received impartiality than it is about impartiality itself. Before the election when there was arguably the possibility of the ALP government's fibre-to-the-premises or FTTP, column-miles were written in barefaced support. 

The support I've always been most interested in was that which put the fibre broadband in the limelight as a delivery platform for public policy outcomes, in particular as the only thing that was in the way of those outcomes being delivered and the only thing missing from delivering them.  The most obvious example of this has been writing in support of telehealth outcomes, in particular from the ABC's Nick Ross.  Nick isn't unique. A lot of writing has gone on and a lot of quotes have been given which mischaracterise the issue. Some of the conversation around the issue in journalism and blogging is outright wrong, some of it only tells half the picture, lots of it comes from people or entities who we can't objectively listen to on the issue because their primary interest in the discussion is leading it in a direction where their goods and services are in higher demand. High speed broadband policy and healthcare is a mess that I'd like to understand the true story behind, so I thought I'd find out, and find out by asking some people I could trust both as experts in the field and as people motivated by their areas of expertise, not by the commercial or ideological benefits nationalised ultra-high speed broadband might bring.

Associate Professor Sabe Sabesan is the director of medical oncology at the Townsville Cancer Centre at the Townsville hospital and responded to my questions on behalf of the Clinical Oncological Society of Australia. I asked him what high speed Internet meant to the delivery of healthcare services that he specialises in, and predictably he did say it's important. In particular;

Speed of the internet is important for real time video conferencing for multidisciplinary meetings and patient consultations (some consultations link 3-4 sites at once including family members from different states or towns).
Stability and clarity of the network is essential to mimic the face to face encounters, and most consultations would involve sharing of desktops to show scans and other images.

That's unsurprising, I knew that video conferencing helps support medical service delivery although I'd only really considered scenarios where a patient met with a healthcare professional one-to-one, I was surprised to learn about multipoint as an issue. Does this translate as demand for Fibre to the Premises?

GP2U is a Tasmanian service that their site says is "founded with the specific goal of facilitating the uptake of Telehealth by solving the key issues that present barriers to uptake. Our mission is to make high quality health care more accessible by using technology to bridge the gaps that separate patients from doctors and other health care providers. "  In short, they are an existing telehealth provider that operates without nationalised fibre broadband. Their speed test page on their website advises;

You need an upload speed of ~400 kbps (0.4 Mbps) for good video conferencing. More is better. Note that an upload speed of 750-800 kbps is about as good as it gets in Australia using ADSL. Fortunately this is adequate to support a single video conference at a time.

I'm skeptical that 400Kbps is the type of speeds that A/Prof Sabesan is looking for, but an existing provider of services that links healthcare professionals with their patients in Australia advises this is what they need for one individual teleconsultation session between two people. Even if we say they've underestimated what's required five-fold and you need 2000Kbps or 2Mbps to deliver these services at high quality, which policy plan is able to deliver? The coalition's at 50Mbps - 100Mbps or the ALP's at 1000Mbps?  And is high speed all we need?  A/Prof Sabesan has more than speed on his wishlist;

High speed internet is only for taking the providers of services closer to homes faster and in a real life like manner, that is, to connect people faster and smoother. You could transfer images faster, you could use diagnostic tools like ophthalmoscopes better, but if you want to provide treatment that is not currently available at a particular site, you still need the infrastructure. For example, in Townsville, we are trialling a remote chemotherapy supervision model. Here medical and nursing expertise are provided to rural generalist doctors and nurses via telehealth. But we still need the chemotherapy chairs and drugs and staff to administer treatment who are available locally.

I'll admit that made me a bit emotional. I lost my mother to cancer and know full well how difficult chemotherapy is, I'd never turned my mind to what's needed to make it better though.

You can connect the world of Australian medical expertise to the people who need it most in the farthest reaches of Australia, but if you don't have somewhere for the patient to sit and someone to put the needle in their arm, all the high definition video in the world isn't going to result in a panacea.

So we need more than speed.  If we had parallel investment in chairs and needles and nurses and screens and people to maintain the screens and people to teach people how to maintain the screens we'd be there right?

Maybe not.

Dr Trent Yarwood is, among his other faults, a friend of mine and a Queenslander.  Trent's an infectious disease specialist and I asked him if telehealth and teleclinics were good ideas that are just poorly supported, or whether there were other problems too.

The issue with teleclinics is logistic.

Contrast me seeing you at my hospital with the telehealth equivalent. In a hospital the clinic staff put your chart outside my room. I pick it up and read the GP's referral and the first and most recent outpatient letters and the most recent discharge summary, as well as anything else that catches my eye. Look some results up on the computer. Then I call you in, take a history, make some notes. I examine you, make some more notes, talk some more while writing out a prescription and send you on your way. Dictate a letter.

With teleclinics, the notes available are whatever has been scanned and emailed - hopefully the outpatients letters and discharge summaries. No extra info. Look up results on computer. Ask doctor / nurse to bring in patient. Talk to patient. Hope that remote clinician is making good notes. Dictate to them a couple of points you think are important.

Then you ask them to examine something if required. Wait for them to do that and hope they are competent. Wait for them to explain findings. Process findings (you do this on the fly while examining them yourself once experienced). Talk to patient. Dictate a couple more salient points to remote clinician. Tell them what to prescribe, wait for them to write out script. Farewell patient. Dictate letter.

Some of this can be done while waiting on the remote site, I never saw a telehealth patient that didn't take at least twice as long as in person. This is agnostic of fibre, satellite or copper, it is just inefficiency from not doing something yourself.

This makes sense. No amount of QOS will make a nurse explain something quicker or better.  What if it got more efficient over time? Well, according to Dr Yarwood you'd still then have to deal with people rorting it.

All (outpatient) medical services have a medicare item number.  Eg a "23" is the standard GP consultation.  A new specialist consult for me is a 110 and a review is a 116.  How much the government pays is listed here.  If doing a consult by telehealth, there is an additional item number - 50% of the standard fee for the consultation. So if I was to see you by telehealth, I would bill a 110 + + 112 (see the notes here ).  The rules have been tightened such that you have to be at least 15km away from me so I couldn't just telehealth you if you could come to see me.

To try and get (technophobic) doctors to take up telehealth, the government also offered incentive payments.  Initially, once you'd a teleconsult, the government gave you $6000 to "offset the costs" of setting up telehealth equipment.  Even if you'd bought a Logitech webcam from Kmart. Anecdotally, quite a few people did this.  The rules have been tightened - the payment is less, and you get part after the first consult and the rest after the 10th.

I'll admit I laughed when I read this, doctors telehealthing patients in the next room with Skype. Like most rorting it was detected and steps taken to improve it at least.

Trent concluded our discussion by pointing out that he thinks telehealth is a good idea, just one with a lot of challenges. I got that feeling from Associate Professor Sabesan too, and I even think it myself.  Telehealth has the opportunity to add spot improvements to the healthcare system but there are challenges to it that mean it will only ever be a complement. Every single time public policy problems are just too complicated to be solved with networking solutions, and the health system was never going to be paid for with GPON.