By Edward Brown
Telemedicine is stretching the boundaries of accessibility, portability and comprehensiveness in health care. The head of the Ontario Telemedicine Network, Edward Brown, feels that policy needs to catch up to new practice possibilities. —Report from a presentation at the 2011 conference of the MUHC-ISAI
Telemedicine provides a vision of what real accessibility, portability and comprehensiveness might look like in the 21st century. As was evident in the 2004 Health Accord discussion, improving access to health care is key to maintaining support for a publicly funded system in Canada. Telemedicine can take our health system to the next level with faster access, better-integrated care, higher-quality care and lower-cost service delivery. However, there are still some important barriers to telemedicine in Canada. Physician fee schedules still insist that a physician be physically present during a consultation in order to get paid, and licensure restrictions on physicians practising in other provinces impede a more sensible use of specialist resources. Policy needs to catch up to new practice possibilities.
In Ontario, geography was the biggest driver in telemedicine. The province is about a million square kilometres, with 12 million people living in the south and only one million in the huge northern area. Access problems to health care were evident early on and telehealth started out in the rural areas of northern Ontario to overcome them. We anticipate that at least 25% of our health care will be delivered virtually by the end of this decade and our ambition is to make telehealth technology mainstream, keep it simple to use and see it integrated into everyday practice.
Clinical telemedicine is two-way videoconferencing, with a health provider at one end and a patient at the other end. Over 50% of telemedicine clinical consults in Ontario are currently in mental health, and the second largest use is in oncology; but almost every specialty can use telemedicine. Even surgeons, while not actually performing the surgery by telemedicine, use it for pre-op assessment, anesthesia assessment and post-op follow-up.
Higher productivity equals greater access
Telemedicine enables specialists to increase their productivity dramatically. Store-forward technology is asynchronous telemedicine that enables a specialist consultation to occur sometime after an examination (i.e. for a rash) is conducted. Images, test results and medical histories are sent by the family physician to the specialist, who reviews them and sends back a diagnosis and treatment plan. In dermatology, asynchronous telemedicine means that people can get a diagnosis in less than six days rather than waiting between six and 18 months for a specialist appointment. The dermatologists find they are more productive because they can eliminate what we call “politeness time.”
The same thing happens with tele-ophthamology. Retinal specialists can more than double their productivity when the face-to-face interaction of receiving and imaging patients is separated from reading retinal images, which is where their specialization is really needed. Given that there are 900,000 people with diabetes in Ontario and that diabetes is the biggest cause of blindness in the province, increasing screening capacity is absolutely essential. At the moment, 300,000 Ontarians with diabetes — fully a third — have not been properly screened.
Telemedicine also ensures that all Canadians have access to high-quality care without necessarily travelling to major centres. Use of OTN has avoided $25 million in travel grants to patients in Northern Ontario had they traveled instead.
Expanded educational opportunities for health professionals and better consultant support help reduce the care differential between urban and rural areas. OTN’s telestroke program allows 20 different hospitals continuous 24/7 access to a neurologist to help their ER physicians decide how to treat a patient who has suffered a stroke and allow them to provide a lifesaving intervention.
The principle of comprehensiveness as understood in the CHA needs to expand to account for current realities, one of which is the prevalence of chronic disease. Telehomecare for chronic disease management is likely the most exciting telemedicine application as we look towards the future. It involves providing patients with specific medical equipment in their homes and pairing them with a coach (usually a nurse), who educates them about their disease and helps them set personal health goals. OTN asked PricewaterhouseCoopers to evaluate our telehomecare program, involving 800 patients with heart failure and chronic lung disease. The program reduced the hospitalization rate in this group by 65% and reduced emergency room visits by 70%. This is especially important given that, according to Ontario Hospital Association calculations, 1% of the population accounts for 50% of the total provincial health expenditures (some $43 billion). That 1% includes a great many people with congestive heart failure, chronic lung disease, diabetes and chronic mental health conditions, which are all conditions very amenable to coaching and improved navigation through the healthcare system. Telehomecare may provide a fairly cost-neutral way to expand the comprehensiveness of our health care system. And patients receiving telehomecare feel like they are actually being looked after and are empowered to play an active role in their care.
Advances such as those seen with telemedicine capabilities stand to improve the care Canadians receive significantly. The challenge today is to develop policies that support team care and the use of technology to reduce cost and improve the quality of care.