Discussion on the Effects of Digital Health Implementation in Australia

Topic:

The digital-health specific strategic vision of Australian federal and state governments suggest that digital health implementation will radically improve access to healthcare. Critically discuss this statement. (You may use examples from other countries to support your arguments)

Background

Digital health can be defined as the use of information and communication technologies for health (1). This embraces all aspects of health such as treating patients, conducting research, tracking diseases, educating workforces, and monitoring public health (1). As digital information and communication technologies have evolved and developed, many of them have been integrated into health to improve healthcare and organisational efficiencies. The main roles of digital health are to: increase access to healthcare, improve safety and quality of care, and improve efficiencies of care (1).

The benefits of digital health demonstrated to be substantial and Australia has developed a National Digital Health Strategy for the implementation of digital health throughout the country (2). The strategic vision for this strategy suggests that digital health implementation will radically improve access to healthcare (2). This will be the topic of this essay, with the objectives of assessing the healthcare issue related to the topic, identifying a digital health solution, and considering key challenges related to digital health implementation.

Stakeholders

Digital health has an abundance of stakeholders as health and the health system affects everybody throughout their lives. Some of the key stakeholders of digital health with specific attention to access comprise of the following:

-          The federal and state governments: access to digital health affects the health of each state and the nation as a whole, therefore the federal and state governments have a particular interest in digital health and providing access to improve health (3).

-          The healthcare sector: as the healthcare sector provides medical services, develops equipment, and provides insurance for healthcare patients, digital health and access to digital health services could dramatically affect the healthcare sector which makes them a key stakeholder (3).

-          Healthcare providers: digital health can transform how healthcare providers deliver healthcare to patients, consequently, healthcare providers have a key stakeholder position (3).

-          Patients: patients are definitely one of the key stakeholders for access to digital healthcare as it can reshape traditional healthcare methods to provide better and more convenient care for the patients (3).

Healthcare issue

The Australian continent is a very large continent which has focused communities and cities generally on the coastline (4). Although most of the population live in these communities and cities, there is still a large amount that live substantial distances from the cities and their services. In 2017, 7 million people (29% of the population) were living in what was considered to be rural and remote areas (4). This poses a significant dilemma for the healthcare industry as the majority of healthcare services are localised in the metropolitan regions. Consequently, there is a considerable gap in the health and wellbeing between the people who live in major cities and people who live in rural and remote areas (4).

The gap in health between metropolitan and rural and remote communities has been studied and important statistics have been identified. People living in rural and remote communities, compared to people living in city dwelling communities are more likely to have a higher proportion of selected health risk factors such as:

-          Being a daily smoker: 22% compared to 13% respectively (5).

-          Being overweight or obese: 68% compared to 61% respectively (5).

-          Having low or no levels of exercise: 72% compared to 64% respectively (5).

-          Engaging in lifetime risky drinking: 24% compared to 15% respectively (5).

-          Having high blood pressure: 24% compared to 22% respectively (5).

-          Having a mental or behavioural problem: 26% compared to 21% respectively (5).

This leads to higher levels of death rates for people living in rural and remote areas compared to people living in metropolitan areas. The age-adjusted death rates for rural and remote people are almost 1.5 times higher than city dwelling people at 759 per 100,000 population compared to 524 per 100,000 population respectively (4). A great deal of these deaths could have been prevented with increased access to healthcare services. This is evident in the potentially avoidable deaths for rural and remote people at 256 per 100,000 compared to metropolitan people with only 96 per 100,000, more than two and a half times higher for rural and remote people (4). Digital health applications and services have the potential to dramatically improve access to healthcare and reduce the gap and inequalities between different population subgroups in Australia.

Digital Health Solution

The proposed solution involves incorporating different aspects of digital health to improve the access to healthcare providers and services to reduce the inequalities between different communities throughout Australia. There are many digital health applications and services that aid in providing access to healthcare in Australia and around the world. Some of the specific services that have been implemented and are proving to be successful include; videoconferencing, teleradiology, teledermatology, telemental health and mobile applications. Each of these applications and services use digital health in different ways to increase the access to healthcare and improve the health of individuals and families throughout Australia and across the world.

Videoconferencing

Although videoconferencing has been around for many years, it has only recently been integrated into health services. Videoconferencing has many benefits in healthcare such as reducing costs and time involved in check-ups and consultations, however, the paramount benefit is improving access to care (6). Incorporating videoconferencing into general practitioner and specialist care can provide access for almost all people living in rural and remote areas of Australia (6). All that is needed for a videoconference is a device with a camera and speaker (such as phone, laptop, tablet, or computer), and an active internet connection (7). As these devices are extremely common, and the internet can be accessed from most parts of Australia, implementing videoconferencing throughout the health services could dramatically increase the access to healthcare for rural and remote Australians (7).

Videoconferencing has proven to be successful in many health applications such as pathology, dermatology, paediatrics, ophthalmology, cardiology, radiology and psychiatry (6). In most cases the services provided are on par with the services that face to face healthcare provides (6). There is insufficient research displaying how much videoconferencing improves access to healthcare, but it is known that videoconferencing does improve access in many disciplines where it is used (6). This explains that if videoconferencing is up-scaled into other areas of health, it has the potential to dramatically improve access to healthcare without diminishing the quality of care being provided (7). In turn, this will help reduce the health inequalities between different populations in Australia.

Teleradiology

Teleradiology is one of the specialist services that has been providing access to healthcare for many years in Australia (8). Teleradiology involves the use of mainly asynchronous or store and forward telehealth which comprises of information being stored and then transferred at a later time (8). In this case, the information is the radiology images which are sent to specialist radiologists for interpretation to improve the quality of care being provided (8). The 2016 Australian Workforce Report identified that 87% of clinical radiologists practiced in major cities and only 0.5% practiced in a location described as remote or very remote (9). This reveals that it is very difficult for patients to access clinical radiologist services when living in remote or very remote areas as the 7 million people in these areas only have access to 0.5% of radiologists in Australia (9). As a result, teleradiology services have been successful in increasing access to radiology specialists for rural and remote Australians.

Everlight radiology, one of Australia’s largest teleradiology services has been providing teleradiology services since 2006 (10). Using store and forward digital services, imaging can be taken at a hospital and sent to the Everlight radiologists for interpretation. This increases the access for Australians who live in rural and remote areas as they do not have to travel large distances to receive expert interpretations (10). Everlight further increases access by providing their services overseas and for 24 hours a day. This allowed access to specialist radiologist services through teleradiology for over 1,400,000 patients globally in 2018 (10). Consequently, this digital health application can significantly improve access to healthcare services and aid in reducing the health disparities between rural and city dwelling Australians.

Teledermatology

Similar to teleradiology, teledermatology is a service that provides access to specialist dermatologists care through digital health services (11). Teledermatology involves the use of still images from a digital camera or from a digital dermatoscope being sent to a specialist dermatologist for interpretation through store and forward services (11). Videoconferencing services can also be used in teledermatology to assess the patients in real time (11). Both types of these digital health services for dermatology decrease the wait time and improve access for patients in areas where dermatologists are limited (12). In most cases, these services are proven to be just as accurate as face to face dermatologic care, which ensures the quality of care is not reduced during teledermatology (12).

One good example of teledermatology is in the Netherlands where teledermatology was introduced in 2005 (13). Since the introduction of teledermatology, over 130,000 consultations have been provided using digital health services (13). Specifically, in 2015, the teleradiology service provided access to an additional 14,000 patients that may not have been able to access dermatologic care (13).

Furthermore, a systematic review of the use of teledermatology discovered that on average, access to dermatology services was increased by 43% by providing services where patients did not have to travel (14). This reveals that digital dermatology services can radically improve access to healthcare, and are a possible viable solution for reducing the health gap in Australia. 

Telemental health

Another digital health services in Australia is telemental health. Telemental health is psychology, psychiatry and psychotherapy services delivered through digital applications, most commonly, video consultations (15). As there is generally no touch involved in mental health services, telemental health has been proven to be just as effective as face to face services (16). As a result, telehealth services using digital technologies are being effectively used in South Australia. Telemental health was originally implemented in South Australia to support mental health services, however, the benefits were so substantial that telemental health services were expanded on their own (15). In 2016, the South Australian Digital Health Network provided over 24,000 video conferences for all of their telehealth services, with many of these being for telemental health (17). With over 220 video conferencing services in the South Australian Digital Health Network, and over 300,000 South Australians living with mental health issues, the telemental health services have the potential to drastically improve the access to these services, specifically for rural and remote populations (16). Amplified implementation of these services could aid in reducing the health inequalities between city dwelling and rural and remote people in Australia. 

Digital Applications

There are many digital health applications available on mobile and computer devices for the public to access (18). These applications can provide access to professional information and advice on different aspects of health. Some of these applications provide information on general health and wellbeing, exercise, eating healthy, quitting smoking, mental health issues, and many other aspects of health (18). Digital applications rely on people actively attempting to improve their health to be effective (18). Nevertheless, when pursued, digital applications can improve the access to quality health information that consumers can use to better their health. Moreover, some digital health applications can provide direct access to health clinicians for their professional support, or provide information on how to access further support (18). As there are currently thousands of digital health applications on the market, it is impossible to assess their effectiveness and collect data on how much information is accessed through the applications. Despite this, if used effectively, it is thought that these digital health applications can improve the health of individuals who use them (18). This may aid in improving the inequalities between different populations throughout Australia by providing equal access for rural and remote communities and metropolitan communities.

Implementation challenges

Physical Touch

One of the major challenges for digital health solutions is the fact that physical touch is impossible through digital health services (19). This is a challenge as physical touch is an important factor in some medical consultations and check-ups. Practitioners may need to palpate or perform physical examinations which is not possible when using digital health (19). Some examples of this include cancer checks and injury diagnosis. While some services have proven to be just as effective using digital health, others may not be so effective without the option for physical touch (19). This may limit the implementation of certain digital health services.

Effectiveness

As many of the digital health services are relatively new and still developing, there is a limited amount of high quality clinical evidence of their effectiveness (20). Further research is required for digital health services to assess factors such as their effectiveness, their improvements to access, and their cost effectiveness, to compare them to in-person services (20). While there are studies examining these factors in relation to digital health, many of them are not considered to be high quality evidence and therefore, confident conclusions about digital health services cannot yet be made (20). This is a major challenge for the implementation and sustainability of these digital health services as stakeholders are not certain of their effectiveness.

Funding

Relating to the above issue of effectiveness, funding is another challenge for the introduction and sustainability of digital health services. Without sufficient evidence that the services are going to be successful, stakeholders are hesitant to invest funding into the services (21). Most current evidence suggests that digital services can decrease health costs and improve the cost effectiveness of health services, as well as increase economic revenue (22). Though for this to happen, substantial upfront and maintenance costs need to be incurred to implement the digital services, especially at such a large scale in Australia (22). This poses a significant challenge for the digital services to acquire adequate funding to be implemented and sustained throughout Australia.

Conclusion

To summarise, in line with the Digital Health Strategic Vision of the Australian Government, it is suggested that digital health implementation can radically improve the access to healthcare in Australia. Digital health services such as videoconferencing, teleradiology, teledermatology, telemental health and digital applications have the potential to reduce health inequalities between rural and remote communities and metropolitan communities. Despite this, there are still limitations that prevent the widespread implementation of digital health services. The challenges of physical touch, effectiveness, and funding must be resolved to successfully implement digital health services.

References

1. World Health Organisation. Digital Health [Internet]. Switzerland: WHO; 2019 [updated 2019; cited 2019 Oct 24 ]. Available from: https://www.who.int/health-topics/digital-health/#tab=tab_1.

2. Australian Digital Health Agency. Australia’s National Digital Health Strategy. Canberra: Australian Government; 2016.

3. World Health Organisation. Engaging Stakeholders [Internet]. Switzerland: WHO; 2019 [updated 2019; cited 2019 Oct 24]. Available from: https://www.who.int/nationalpolicies/processes/stakeholders/en/.

4. Australian Institute of Health and Welfare. Rural and Remote Health [Internet]. Australia: AIHW; 2018 [updated 2019; cited 2019 Oct 24]. Available from: https://www.aihw.gov.au/reports/rural-remote-australians/rural-remote-health/contents/health-status-and-outcomes.

5. Australian institute of Health and Welfare. Australia’s Health 2018. Canberra: Australian Government; 2018.

6. Speyer R, Denman D, Wilkes-Gillan S, Chen YW, Bogaardt H, Kim JK, et al. The effects of telehealth by allied health professionals and nursing in rural and remote areas: A systematic review and meta-analysis. 2018;50(3).

7. Moffatt JJ, Eley DS. The reported benefits of telehealth for rural Australians. Australian health review : a publication of the Australian Hospital Association. 2010;34(3):276-81.

8. Tie M. Teleradiology in Australia: At the Crossroads of Electronic Health. Journal of the American College of Radiology. 2011;8(1):71-3.

9. Royal Australian and New Zealand College of Radiologists. 2016 Clinical Radiology Workforce Census Report: Australia. Sydney: RANZCR; 2016.

10. Everlight Radiology. A lifeline for vital radiology services [Internet]. Australia: Everlight Radiology; 2019 [updated 2019; cited 2019 Oct 25]. Available from: https://www.everlightradiology.com/au/.

11. Muir J, Lucas L. Tele-dermatology in Australia. Studies in health technology and informatics. 2008;131:245-53.

12. Latifi R. Current principles and practices of telemedicine and e-health. ProQuest, editor. Amsterdam

Oxford: IOS Press; 2008.

13. van Der Heijden J, Witkamp L. 6 years TeleDermatology in The Netherlands: results of 80.000 teleconsultations. Int J Integr Care. 2013;13.

14. Wootton R, Bahaadinbeigy K, Hailey D. Estimating travel reduction associated with the use of telemedicine by patients and healthcare professionals: proposal for quantitative synthesis in a systematic review. BMC health services research. 2011;11:185.

15. South Australia Health. Telehealth for mental health [Internet]. South Australia: Governement of South Australia; 2012 [updated Aug 2019; cited 2019 Oct 25]. Available from: https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/health+services/mental+health+services/telehealth+for+mental+health.

16. Langarizadeh M, Tabatabaei MS, Tavakol K, Naghipour M, Rostami A, Moghbeli F. Telemental Health Care, an Effective Alternative to Conventional Mental Care: a Systematic Review. Acta informatica medica : AIM : journal of the Society for Medical Informatics of Bosnia & Herzegovina : casopis Drustva za medicinsku informatiku BiH. 2017;25(4):240-6.

17. South Australia Health. Telehealth [Internet]. South Australia: Governement of South Australia; 2012 [updated Aug 2019; cited 2019 Oct 25]. Available from: https://www.sahealth.sa.gov.au/wps/wcm/connect/Public+Content/SA+Health+Internet/Health+services/Telehealth/.

18. Marston HR, Freeman S, Musselwhite C. Mobile e-Health. SpringerLink, editor. Cham: Springer International Publishing : Imprint: Springer; 2017.

19. Campion EW, Dorsey ER, Topol EJ. State of Telehealth. The New England Journal of Medicine. 2016;375(2):154-61.

20. Armfield NR, Edirippulige SK, Bradford N, Smith AC. Telemedicine ‐ is the cart being put before the horse? Medical Journal of Australia. 2014;200(9):530-3.

21. Jolly R. The e health revolution : easier said than done / Rhonda Jolly. Australia. Department of Parliamentary Services. Parliamentary L, editor. [Canberra]: Parliamentary Library; 2011.

22. de la Torre-Díez I, López-Coronado M, Vaca C, Aguado JS, de Castro C. Cost-Utility and Cost-Effectiveness Studies of Telemedicine, Electronic, and Mobile Health Systems in the Literature: A Systematic Review. Telemedicine and e-Health. 2014;21(2):81-5.