Telehealth

Horizon thinking

Telehealth is the use of (1)

information and communications technologies to deliver health services and transmit health information over both long and short distances. It is about transmitting voice, data, images, and information rather than moving patients or health practitioners and educators.

In this article, I’m predominantly focusing on video consultations and telephone consultations.

A telehealth consultation

Telehealth in Australia and many other high-income countries has almost overnight become a step transformation in the way care is delivered catalysed by the coronavirus pandemic. As the use of telehealth at scale embeds into the healthcare industry emergent opinions are variable. They range from telehealth is here to stay and will change the way we work forever, to a more conservative, telehealth is an adjunct in our care delivery systems and highlighting potential limitations of telehealth, particularly with respect to undertaking examination. Australian funding for telehealth via Medicare requires providers to offer face to face services if necessary; media has reported regulatory referral for providers who don’t. The Australian Health Practitioner Regulation Agency has reinforced the standards of care for telehealth need to be the same as those for face to face care.

Stage

As a community, we are at a very early stage for telehealth, akin to a toddler going from crawling to beginning to walk. The natural journey for a child is to walk confidently, then start running and then jumping and eventually a composite. Will telehealth also start running and jumping and embed itself seamlessly into our care delivery system, or will it go back to a crawl? The Alchemy of Growth, a book written in 2000 offers a three-horizon framework, a structure with which many companies and innovators think about their strategy. Indeed, examples include the ACT Health’s digital strategy or Queensland Health’s digital strategy, both of which use the three-horizon framework. What does this framework look like for telehealth?

The Coronavirus pandemic has ‘pushed’ most providers into telehealth, but the change curve is slow. Although the number of telehealth consultations has grown enormously, the majority of these in Australia have been phone consultations rather than video consultations, despite a preference for video consultations being explicit in the funding criteria. It is not surprising as first horizon ideas only bring short-term innovations to an organisation’s existing business model and core capabilities. What we have seen is everyday technology, the telephone, being utilised to deliver some elements of care but at scale. As people do so, benefits and limitations are experienced. The universal access to telehealth in Australia (enabled through temporary funding changes) presents an enormous opportunity for future care delivery models.

What might we observe in Horizon 2? Perhaps an explosion of apps and technologies that augment telehealth. One of the most frequent issues I hear in our current telehealth paradigm is ‘we can’t do that because we can’t examine the patient.’ Abdominal examination is a commonly cited example. The use of accelerometers in smartphones, however, can support a clinician to undertake a remote screening assessment for abdominal issues. Another planned study will investigate if the decision making on the choice of investigations for abdominal emergencies is any different when undertaken by remote assessment compared to face to face assessment. Another utility for telehealth is to offer remote monitoring abilities for patients with complex and chronic conditions. An Australian trial examined the provision of telehealth monitoring for older adults with chronic conditions and found a significantly reduced mortality and efficiency savings, with a return on investment of 5 to 1. Although small and specific, the concepts have been brought together into a service offering in some markets. For example, diagnostic devices are marketed to consumers, which can facilitate a remote examination of the ear, throat, auscultation of heart, lungs and abdomen as well as high-resolution skin lesion assessments. Horizon 2 is about extending organisations existing core capabilities and business models to new customers, markets, or targets. It is therefore easy to see how as telehealth embeds itself in Horizon 1, a selection of complimentary tools may emerge to help address some of the challenges of telehealth. Horizon 2 describes the sector shifting from a crawl to a confident walk.

So, what does horizon three hold? In some ways, horizon three will be a natural evolution of the improvement cycle from the preceding horizon but a focus on healthcare provider building new capabilities and models to harness the disruption created in horizon 2. As I imagine it, horizon 2 will have many telehealth platforms, supporting tools and apps, but they may not be connected. They will all have utility but will need workarounds and motivation to use because they’re not integrated. Horizon 3 is likely to be an era of integrated and interoperable platform-agnostic telehealth systems. These systems themselves embedded into an integrated service delivery offering virtual care and face to face care. Imagine an era where several service offerings come together into one portal; the electronic medical record, the telehealth platform covering the spectrum of telehealth as well as chatbots, integrated tools to support telehealth, the ability to create electronic secure paper flows (prescriptions and referrals) and secure information exchanges integrating multiple data sources including those from wearables and remote monitoring devices. Artificial intelligence and machine learning supporting the synthesis and analysis of the numerous data sources. What will emerge is a virtual care system; there already are examples.

Three horizons

The three-horizon framework is perceived as a temporal sequence of each of the horizons. However, since its first articulation, an article in the Harvard Business Review argued the temporal element of the framework no longer applied. The reason being the time from horizon one to horizon three can be enormously quick. The article cited some disruptors such as Uber, Tesla and Airbnb as case studies. It concluded that “many disruptions can be rapidly implemented by repurposing existing Horizon 1 technologies into new business models — and that speed of deployment is disruptive and asymmetric by itself”. The healthcare industry at large in Australia has started to crawl in its telehealth journey but will it learn to run and jump and harness the best of digital disruption and at the same time keep the best of current models?

(1) Deshpande A, Khoja S, McKibbon A, Jadad AR (2008) ‘Real-time (synchronous) telehealth in primary care: systematic review of systematic reviews.’ (Canadian Agency for Drugs and Technologies in Health (CADTH): Ottawa)