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Is Telehealth the Right Tool for Remote Communities?: Improving health status in rural Australia

Isabelle Ellis
Lecturer, Rural and Remote Practice (Nursing), Combined Universities Centre for Rural Health, Curtin University of Technology, Geraldton WA

Abstract

The health status of people in rural and remote areas of Australia has been widely reported to be poorer than their urban counterparts, particularly Indigenous Australians. Health care in rural and remote Australia has relied on the work of nurses, often in the absence of medical or allied health personnel other than via telecommunication.

Over the last 5 years telehealth has been heavily promoted as an innovative and effective way of improving the health status of people in rural and remote areas by providing improved access to specialist care. Through national infrastructure development and funding for a vast array of pilot projects telehealth has been promoted as progressive, effective, and modern.

This review examines the literature and highlights a need for additional research around telehealth-mediated patient-practitioner relationships.

Keywords

telehealth, rural health, patient-practitioner relationship

Article Text

This has had significant influence on healthcare organisational structures and the roles of health workers involved in its delivery (Sinclair-Jones, 2000; Willis, 2000).

In the past 5 years there has been a rapid roll out of telecommunications and information technology infrastructure to the rural and remote areas of Australia. This has been substantially funded by the partial sale (privatisation) of the telecommunications carrier in Australia, Telstra. Through a Commonwealth Government initiative ‘Networking the Nation’ a large number of Telehealth programs and projects have been piloted. Telehealth can be simply described as health care services at a distance (Darkins & Carey 2000). It encompasses the use of videoconference technology for direct patient consultation, store and forward technology such as email and teleradiology and the use of the internet for access to health information. It is commonly broken into medical sub-specialities such as teledermatology, telepsychiatry and teleopthalmology, to name the most common services being piloted.

Using technology to provide access to necessary health services for people living in isolated areas of Australia is not new. The Reverend John Flynn piloted the use of the pedal radio to transmit medical information in the early 20th Century from the remote outback. Remote area nurses and Indigenous health workers have provided health care services to remote communities with initially radio back up and now telephone back up since as early as 1917 (National Archives of Australia Fact Sheet 159). When the skill required to care for the patient falls outside the ability/competency of the resident health professional the patient is still, as always, transported to a referral centre for expert care.

In 1996, 30% of Australia's population lived in rural and remote areas (Australian Bureau of Statistics 2002). Only a very few medical specialists were available in rural areas and in remote areas medical specialists remained virtually non-existent (van Gool et al. 2002). Nurses constitute almost 56% of the total rural and remote health workforce (Australian Institute of Health and Welfare 1996). As a means of making specialist services more accessible to people in rural and remote areas telehealth has been seen as an obvious solution. It is seen to be able to reduce the cost of travel for both patients and specialists and reduce waiting times for patients who would normally have had to wait the set time between visiting specialist visits. It is also seen to be able to provide access to a greater variety of specialists, including nursing and allied health as well as medical specialists (Coiera 1996; Davis et al. 2001; Grigsby et al. 2002; KPMG Consulting 1999).

Governments have funded the majority of the cost of the expansion of the communications network and the benefits of being connected have been heavily promoted to both patients and health care providers (Horsfield & Peterson 2000). This paper will critically examine the assumption that by making technology available, and providing telehealth access to specialists, health care and health status of rural and remote Australians will be improved.

Seeing the patient

According to Sinah (2000, pp.292) in the Western scientific tradition, vision is regarded as the sense least subject to interpretation or ambiguity of meaning. Visual imagery is thought of as the most efficient mode of communication...the visual sense is the most refined in the practice of medicine and has largely replaced the use of other senses.

Sinha implies that sight is a very powerful diagnostic tool and a visual picture is superior to a spoken word picture or a written word picture. Health professionals have decreased their reliance on auscultation, in favour of more visual media. The X-ray is considered superior to the stethoscope in diagnosing lung problems. Not only are we able to see into the patient's chest we can create a permanent record of that vision to be discussed with others who can then give us their interpretation.

Currently one of the most successful uses and heavily promoted forms of telemedicine is teledermatology (Wootton & Hebert 2001). Teledermatology allows a wound image or skin lesion to be captured and transmitted electronically to the wound care specialist or dermatologist. The wound or lesion is detached from the patient, calibrated to a standard computer image, which is then emailed and assessed. Teledermatology enables the specialist to monitor the wound healing rates electronically by serially measuring the different types of wound tissue and the depth of the wound creating a pictorial record. Teledermatology may enable specialist input into wound care practices in rural and remote Australia to assist nurses to better manage the wounds they see but may not necessarily assist them to assess and manage the complex care needs of diabetic patients with lower limb ulcers.

Nurses practicing in rural environments with limited or no onsite medical support are required to be advanced generalists, they must be prepared to face all challenges as they present, as are their limited medical and allied health colleagues. Patients come as a package, with often many co morbidities that require a team to manage them (Wilkinson & Blue 2002). Telehealth as it is being proposed in its segmented specialties cannot provide that service. Furthermore there is a risk of assuming that by providing a telehealth service communities will be better off. (Cramer 2000) contends that rural and remote nurses should advocate on behalf of communities by demanding equitable services.

Sinha (2000) has suggested that telehealth may reduce the power imbalance between the health professional and the patient since both the patient and the doctor view each other via television. This may hold true for videoconference-mediated consultations. The most commonly used videoconferencing is for telepsychiatry. The mental health professional is able to speak with the patient directly via videoconference. The patient is similarly able to view the mental health nurse, psychologist or psychiatrist. In reality the mental health professional rarely wants to examine any other part of the body than the patient's thoughts and affect and can perform their complete examination through the videoconference at a particular sitting. The mental health professional is familiar with the technology as they use it to consult on a regular basis with a variety of patients. The patient is required to submit to yet another foreign experience and engage with the health system through the unfamiliar medium of the videoconference.

Telehealth is said to be able to combat social exclusion, increase social cohesion and bring health care to the worst off by creating the ability to share experiences and provide help that is community based, such as self-help groups on the internet (Klecun-Dabrowska & Cornford 2000). This is assuming that consumers who are worst off in our community are on the have side of the digital divide with both knowledge and access to technology to be able to participate in self-help groups on the internet.

Horsfield and Peterson (2000) propose that the State funded and driven diffusions of new social technologies such as telehealth enacts discourse that rely upon unquestioning general acceptance and application of ideologies such as national development, progress, efficiency, economy, rationalisation of health services and modernisation; whereas Klecun-Dabrowska and Cornford (2000) suggest that telehealth technologies might be deployed and used to serve the aims of social cohesion and personal freedom, or they may lead to social exclusion and a control regime for the provision of health care.

The therapeutic relationship

Conventional face-to-face consultations currently rely on therapeutic relationships to care for and cure patients. Miller (2002) cites a great deal of research around the doctor patient relationship. The nurse patient relationship has also been widely researched (Chang et al. 2001). Much store is placed on the sanctity of the confidential nature of those relationships. According to Miller (2002) communication behaviours are an important determinant of health outcomes. Miller also suggests that the patient may have a negative health outcome if the auditory and visual quality of the transferred information is deficient. This suggests that the better the picture the better the health outcome for the patient. Very few studies have examined the effect of telemedicine on the nature and content of health professional-patient communication (Miller 2002).

Many telemedicine encounters require the addition of a third party in the consultation. This may be either the primary referral practitioner or a separate third party to assist the patient with the technological side of the referral. In many instances patients provide an illustration for practitioner-to-practitioner communication, ensuring the specialist's instructions are clearly understood and able to be demonstrated. The impact of this intermediary on patient satisfaction with the therapeutic relationship has not been evaluated.

Direct contact, albeit remote, constitutes a therapeutic relationship. Store and forward technology such as described earlier in teledermatology allow the specialist to have a relationship with the patient's wound but often the specialist is one step removed from the patient and the relationship is with the treating practitioner.

Patient satisfaction with telehealth services

Patient satisfaction reflects patients' values and expectations regarding various aspects of a health service (Yip et al. 2003). Patient satisfaction with the therapeutic relationship has been studied extensively and tends to be associated with: more information giving, more positive affect, more social conversation, more psychosocial talk, more partnership building, a warmer, more immediate non verbal manner (Miller 2002).

Patient satisfaction with telehealth consultations have been measured to include audiovisual quality, general level of satisfaction, degree of accessibility, use of equipment (KPMG Consulting 1999; Chang et al. 2001; Davis et al. 2001). There is very little research on patient satisfaction with the quality of the interaction in the therapeutic relationship in a telemedicine consultation (Sinha 2000; Miller 2002).

Conclusion

Telehealth has been described as the negotiation of health care between providers and patients, linked across space via telecommunications technology (Sinha 2000). This definition implies that telehealth is providing a health service to patients. In the early days of telehealth in remote Australia the majority of the telehealth provided a back-up service to practitioners. Local practitioners examined the patient and when the problem was beyond their level of expertise they sought information from an urban or regionally based specialist. The patient rarely spoke to the specialist unless it was decided by the two practitioners that the local practitioner would endanger the patient by providing the recommended treatment and the specialist was either brought to the patient or the patient was brought to the specialist, hence the birth of the Royal Flying Doctor Service (van Gool et al. 2002).

The widespread use of visual imagery in the telehealth consultation commenced with the fax machine. The medical specialist's eyes was extended to the outback. The practitioner was able to send an ECG to the specialist and gain instantaneous feedback by phone. Decisions were then made about the urgency or the need for evacuation. With the ability to access videoconference facilities; and internet and email now widely available, in even very remote areas the medical gaze is being further extended. In this environment telehealth can be seen as being able to help the primary sector provide a wider range of services, access continuing education, and enable communication and cooperation between different institutions. Concurrently telehealth can be given a role in controlling the treatment practices of primary care practitioners, limiting professional freedom and introducing managed care.

Patient satisfaction with the telehealth service needs to evaluated, not just the audio visual quality of the consult, or the use of equipment, but the interaction between the patient and the practitioner. The patient's view of the role of the remote specialist and the effect of technology mediated consultation on that therapeutic relationship also needs to be evaluated (Sinha 2000; KPMG Consulting 1999; Miller 2002).

Despite improved access to infrastructure in rural and remote Australia, while telehealth services remain an optional extra for the technology enabled health practitioner or patient there is limited scope to improve the overall health status of rural and remote Australians. At best telehealth can provide a more sophisticated back up for rural and remote practitioners, or a second opinion for patients.

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