The Australian Government’s $618.5 million telehealth scheme has been likened to the pink batts scandal, with fears medical professionals may be able to secure $6,000 grants for doing little more than making a Skype call.
The initiative, which seeks to encourage take-up of videoconferencing for consultations between medical specialists and regional Australians, went live on Friday July 1.
As well as covering telehealth sessions under Medicare, the initiative offers financial sweeteners to doctors aiding patients on-site and specialists conducting remote consultations.
These include a $6000 one-off “Telehealth On-Board Incentive" for making their first consultation during the 2011-2012 financial year, and payments of $60 a consultation thereafter.
The Department of Health expected to spend $12.3 million doling out the individual incentives over the next year to specialists and practitioners and to fund facilities for the scheme.
This would increase to $48.6 million by 2014-2015 as adoption increased, although the one-off on-board incentive would drop to $3,300 per professional in the same period.
However, precisely what would constitute a valid telehealth consultation for the purpose of receiving such grants has not yet been made clear by the Government.
A consultation conducted over a browser-based service such as Skype could easily meet the requirements necessary to earn the $6000.
One former Department of Health official said the lack of governance could make the telehealth initiative “Nicola Roxon’s Pink Batts scheme”.
Technology neutral
The Government has been careful “not to mandate any particular technological solution” so as not to lock Australia’s health industry into one provider.
The “particular hardware or software methods for consultation should rest with the clinician,” the Government’s MBS web site states.
The Government has released a series of technical guidelines for hardware-based systems it hopes clinicians may adhere to, but has not set these guidelines as requirements for funding under the telehealth scheme
The only requirement to pick up a $6,000 grant is that the telehealth session is conducted over "audio-visual link."
Beyond those guidelines, the only standards medical professions can rely on are clinical standards under development by the Royal Australian College of General Practitioners (RACGP).
The RAGCP approached the Government late last year to formulate clinical standards around telehealth but had been pushed back by legislative and financial obstacles until it was officially awarded the contract in May.
As a result of the delay, the college has undergone an “accelerated” process of developing the standards - which would usually take up to a year. The college will hold a public consultation next month ahead of ratifying a clinical standards document in October 2011.
Though touching on some technical aspects of using videoconferencing, the college was given no brief to mandate specific technologies or minimum technical standards.
These standards will also apply only to GPs and their staff - not the specialists on the other end of the line.
Funding will have been made available to medical professionals for at least three months before any governance is introduced.
A spokesperson for the Federal Department of Health and Ageing said the uptake of the MBS rebates and incentives “is being closely monitored by DoHA and Medicare Australia".
Clinicians would need to use services “capable of providing sufficient video quality” for the service being provided, adhering to security and privacy requirements under Australian law.
“Any schemes which would appear to abuse or rort the arrangements will be investigated,” she said.
The spokesperson said the incentive program was established under Medicare administrative guidelines rather than coded into legislation, enabling requirements to be “adjusted quickly” if rorts or loopholes are discovered.
Low-bandwidth options
Medical professionals have already been offered services from telehealth start-ups set up to take advantage of the Government sweeteners.
One such offer, made available from Queensland-based ConsultDirect Australia, a subsidiary of medical software firm Medilink Australia, offers a directory of specialists that GPs can connect with via video link to qualify for the scheme.
The ConsultDirect subsidiary was formed expressly to take advantage of the Government’s telehealth scheme. It asks doctors and medical professionals to join for $11 a week to use the service and satisfy the conditions for the one-off incentive and ongoing consultation rebates. GPs can also choose a pay-as-you-go system, paying ConsultDirect for every consultation.
The service is based on a free widget hosted by San Francisco-based Tokbox. ConsultDirect has integrated the Tokbox widget with a billing, scheduling and auditing system that allows for the video calls to be complemented by secure (encrypted) exchange of medical documents such as radiology scans, high-resolution photos and referral forms.
Dr Henry Glenie, a Cairns-based ear, nose and throat specialist and chief operating officer at Medilink Australia, told iTnews the application was developed over the last six months to meet the needs of those doctors and specialists that could not afford expensive telepresence systems, but wanted a superior solution that free services such as Skype.
“Doctors could go onto Skype,” to earn the Government handout, he said. “But then the patient has your email. On our system you have to register at each end.”
Dr Glenie said hardware-based videoconferencing and telepresence systems, at the other extreme, were “cumbersome to set up” and required medical professionals to leave their offices to take a call. “A lot of time is wasted, and sometimes patients don’t turn up.”
Some 200 medical professionals - mostly specialists - have registered to use the ConsultDirect service, he said.
Dr Glenie defended the webcam user experience on the Tokbox-based system, as it “could be complemented with a telephone call or high definition photos.
“What specialists want to do is get a feel for what the problem is,” he said. “I think it is workable.”
Dr Glenie said that to his knowledge, Tokbox runs the unencrypted video streams from a data centre somewhere in Asia, but is not recorded or stored by ConsultDirect.
Tokbox have given the company no assurances it is not storing the video data.
ConsultDirect's IT manager, who wished not to be named, said the Government’s technical guidelines only applied to hardware systems too expensive for most practices to consider and “haven’t really accommodated browser-based systems.”
The Department of Health and Ageing told iTnews that its initial assessment of ConsultDirect would be that its “services appear to be in order.”
Read on to find out why the Royal College of Practitioners is concerned about the lack of technical standards...
RACGP concerns
Dr Sue Page, a telehealth consultant with the RACGP, expressed concerns that low-cost options could impact on a doctor’s ability to properly diagnose or treat a patient by videoconference.
“If the image is tiny and grainy, it may impact on your ability to make a sound medical judgement, and therefore you may be exposing your patient to risk,” she said.
“You are obviously compromising care if there is some aspect about that patient’s care that requires a good visual feed or a good audio feed and the technology can’t deliver that.”
Dr Nathan Pinskier, a member of RACGP’s e-health working group and former clinical lead with NEHTA, said the national body for medical professionals was concerned about the lack of technical specifications.
He advised Australia’s medical professionals to “proceed cautiously” and not be tempted to “rush in to telehealth with a low-bandwidth solution”.
The college has looked to tie some limited technical considerations into the clinical standards it is preparing, but Pinskier said the college “doesn’t own the technical space” and instead hoped the Government would work with the college and the technology community to solve the problem.
“There is a real risk,” he said. “If you create a model where the trigger event for funding is the first call, there is temptation for some providers to jump in, get a $35 high definition camera and go. It may work fine the first time, but maybe not the second time.
“If services like Skype are proven to not be secure, given that data is transmitted on a peer-to-peer network, someone’s clinically sensitive data could wind up in someone else’s domain, and this could undermine the Government’s telehealth initiative.
“If people lose confidence in the process, it will die. The Government will have funded a white elephant.”
Dr Pinskier said some of the key technical requirements to consider included adequate levels of bandwidth, technical support, failover and redundancy and ultimately – security and privacy.
The challenge would also be to create a state of interconnectivity between various teleconferencing technologies.
“We don’t want to end up a world where specialist and a GP need ten different technology solutions to communicate,” he said. “That’s the risk we currently face.”
The problem had already arisen, with some hospitals refusing to allow open access to their existing videoconferencing solutions - which often used proprietary systems - to outside doctors and specialists.
Doctors would also need to accept the added responsibility of properly identifying a patient in consultation - usually undertaken by a receptionist - as per existing standards for accreditation.
Cautious by nature
Dr Page said it was unlikely that medical professionals would adopt any system “gung-ho” without waiting for some protections around clinical safety.
A similar scheme to encourage telehealth adoption by psychiatrists had been met with caution since their consultations become eligible for MBS rebates in 2002.
Public figures indicated that only 100 sessions have been held per month by the specialists. Some $1.7 million was paid by Medicare items to those participating between 2005 and 2007 for a total of 1,613 online consultations, or an average of $1,000 per consultation.
Dr Glenie feels that the $6000 start-up grant was unnecessary.
“Why they dreamed up that sum of money I can’t say. It might work for a group of 12 doctors in a large surgery, a $600 payment would have been enough for an iPad 2.”
“The Government wants to see things happening, that’s why they have not prescribed how to do it.”
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