Editorial - Telehealth

It is with pleasure that I introduce the June edition of Health Care and Informatics Review Online, which explores telehealth, an exciting and rapidly growing area in the application of health informatics.

Simply put, telehealth is the use of various information and communication technologies to provide health care when provider and recipient are separated by distance.

The type of telehealth activity being employed will dictate to some extent the level of technological sophistication required and, thus, the method of communication. However, there are often different ways to accomplish a similar activity, eg, contact a distant specialist via a dedicated webpage on the Internet or via a live video-conference through a proprietary communications network. A number of factors will influence choice including available resources, services, and technical, support; the interest, knowledge and skill of the user; and the level of development of the health system.

Regardless of the choice of technology, telehealth typically serves to address "inequities" in the distribution of healthcare resources. This role is reflected in the papers presented in this edition, for example in their references to the use of telehealth for the provision of services to remote or rural areas where resources are more limited.

In our guest editorial this month, Karolyn Kerr, Consultant, Wellington, New Zealand, notes the important opportunity that secure broadband offers in supporting the delivery of more equitable health care in remote communities by enabling a range of telehealth services. Kerr points to the many Government projects aimed at using ICT to improve delivery of government services; while these projects are not specifically health-related, they may provide opportunities for expanded geographical access to broadband networks.
Kerr notes the requirement for four independent infrastructure components within telehealth, client provider and clinical services infrastructure, governance infrastructure, management and operations infrastructure and technology infrastructure, all of which need to be addressed coherently to ensure a high quality telehealth service is available and usable by the clinician and administrator.

Importantly she highlights the need to establish collective requirements on a national level across clinical services to allow an aggregated approach to procurement of bandwidth, hardware and other resources common to all or most telehealth services.

In "Build, Be Flexible, and the Patients Will Come? – Lessons Learned in e-Consulting", Peter Yellowlees, Professor of Psychiatry, UC Davis, California, USA reflects on his involvement with Doctor Global Ltd, a small New Zealand health information technology (IT) company that developed a series of excellent and broad-ranging telehealth products.

Yellowlees walks us through the fascinating transition of Doctor Global over five years from health service provider to medical software developer providing IT disease management solutions for health groups involved in chronic disease management.

Doctor Global was originally founded as a health service company to provide a facility for general practitioners (GPs) to undertake email consultations with patients and for patients to seek a second opinion from specialists. A transition into provision of consumer-centric personal health records followed. These multimedia, Internet based, personal electronic health records (EHR) could still be used as an underlying infrastructure to support electronic consultations, but also provided patients with a portable potentially "complete" record of their health status, from birth to death. The patient-centric nature of the records gave consumers control over access and negated the issues surrounding the consent and privacy of such information. Although, issues with the business model limited the EHR product’s success, the process of identifying "niche markets" for personal electronic records, highlighted an important opportunity for Doctor Global in electronic disease management. Redeveloping the interface and adding various communication options such as chat rooms and voice-over IP led to the development of a comprehensive disease management record.

Yellowlees notes an important lesson from the Doctor Global experience, that of timing of the introduction of telehealth products. Despite technical excellence, high quality, and usefulness, online consultations and personal health records were ahead of their time, and not supported by sufficiently advanced attitudinal change and acceptance among providers or patients.

In their paper "MHWD Telepsychiatry Project 2004", Robyn Shearer, Workforce, Mental Health Directorate, Ministry of Health, Wellington, New Zealand and Sandy Macaulay, Project Manager, HealthMAP Limited, Auckland, New Zealand introduce the MHWD Telepsychiatry Project, an initiative within the Mental Health Workforce Development (MHWD) Programme to enhance and encourage the use of video-conferencing within the mental health sector, for clinical purposes and workforce development initiatives.

The project aim was to support effective use of existing equipment where possible and to provide the support required for current and future purchase and use of video-conferencing equipment in the Mental Health sector.

Video-conferencing is recognised in mental health services as a tool to provide access to clinical training and professional development, clinical supervision and access to peer review or second opinions for clinicians from rural or remote areas, and a means of supervising mental health services consumers when they return to a rural or remote area.

The MHWD Telepsychiatry Project was a national initiative, providing a central infrastructure via a website providing a national repository that offered information on clinical and organisational guidelines and clinical and technical standards for the use of video-conferencing.

Shearer and Macaulay review the key problems relating to the operation and acceptance of video-conferencing in the mental health sector, summarising issues and potential solutions for each. For example, they highlight that a centrally managed infrastructure and administration, through which telecommunication and equipment contracts can be negotiated to maximise economies of scale can assist to achieve a cost-effective video-conference network.

The paper presents recommendations from the MHWD Telepsychiatry Project split into two options. The first option is aligned with the review of a national telehealth strategy for the health sector sponsored by the Ministry of Health. The second option proposes addressing the requirements as set out in the MHWD Telepsychiatry Project by providing a mechanism specific to the mental health sector.

Shearer and Macaulay conclude that a cost-effective network/infrastructure for a successful video-conferencing facility within the mental health sector requires a nationally managed IP-network-based secured video-conferencing infrastructure and needs to be part of the national strategic direction recommendations of the Telehealth working group for New Zealand.

In "Teledermatology Today", Amanda Oakley, Clinical Associate Professor, Waikato Clinical School, Faculty of Medicine & Health Science, The University of Auckland, New Zealand and Clinical Director, Department of Dermatology, Health Waikato, Hamilton, New Zealand, sets out the requirements for successful teledermatology including simple interfaces, rapid communication systems and trained users.

Oakley describes both interactive and store-and-forward methods in telehealth and their application in dermatology.

A review of successes in teledermatology highlights benefits for both patient and physician and potential cost savings for health services. Oakley also points to the issues that can occur with even the best-intentioned ad hoc services in telemedicine citing lack of sustainable funding, lack of physician adoption, concerns about medical indemnity, poor quality equipment or lack of need.

Oakley reviews the status with and clinical protocols and standards for telemedicine, noting that these are still evolving. However, importantly, she notes that teledermatology is expected to have an increasing role in patient care as secure broadband communication systems become widely distributed in health services.