Let's Talk about Telemedicine

7 min read August 10, 2012 at 10:44am on Computing, Health, NBN and Rant

So... I may have lost it a bit on twitter yesterday. Lots of potential excuses... our son isn't sleeping well, staying up too late, ongoing uncertainty about job security. But here is the main one:

xkcd: Duty calls
xkcd: Duty Calls - CC-BY-NC 2.5 - Original Link


Brief disclaimer first.   I'll happily admit that I'm a bit of a geek.  I've been fooling around on computers since 1988, build my own computers and can edit the registry by hand and compile programs in Linux. I don't have any formal qualifications in computer science and I make no claims about being a network engineer.

What I do know, though, is healthcare.  I've been training in medicine since 1998, worked full-time in the public healthcare system from 2003-2011 and have been working flitting between the corporate office and population health side of health, private medicine with a bit of public medicine on the side. 

My jeopardy special topic is infectious diseases, but as part of medical (that's medicine as opposed to surgery, not medicine as in all doctors everywhere) specialist training in Australia, you are required to have broad general experience before moving into your specialty area. 

I've worked in an Acute Stroke Unit, done stroke rehab and worked in cardiology units, so I'm not without experience in these areas.

The ABC's Tech Editor, Nick Ross is generally worth reading (follow him on twitter here) and wrote a cracking response to the internet meltdown about violent games following the Norway Massacre.  He's been a very vocal advocate of the NBN and seems to have taken with gusto to trying to demolish the Opposition's opposition to the NBN.

But he continues to spout crap about how the NBN is going to revolutionise healthcare. It all seems to have begun with talk about stroke rehab - which at least has some basis in reality.  The group lead by Professor Penelope McNulty has been looking into the role of a modified version of WiiFit for stroke rehabilitation for patients in remote areas without access to formal stroke rehabilitation units.  The NBN website has her work listed as a case-study of NBN-awesomeness. 

So where does the NBN come into this exactly?  A therapist (most likely a physiotherapist) gets feedback on movements made by the patient on their Wii and can taylor exercises for the patient. I think this is great.  Increasing access for people in remote areas to stroke rehab is excellent, no arguments there, and the application of the technology seems to be a sensible one. What if your stroke leaves you so physically impaired you cant work your Wii?  Or affects your thinking, or language?  Or your ability to swallow? Or your vision?  Or any of the dozens of other functional impairments you can be left with from a stroke?  Sure, some speech therapy can probably be done via video link, but if the Speech Pathologist wants to assess your swallow accurately and safely, they need to spoon some blue goop into your mouth and watch how your laryngeal muscles move (apologies to any speechies for the reductionist description).

So, let's change "allow stroke rehab at home"  to  "allow some patients with a limited set of disabilities undertake focussed rehab for a specific set of problems at home, as long as they are able to use the technology".

Telemedicine in general is fraught with problems.   I've done a teleconferenced clinic - it is awful.  You need another doctor (preferably, nurse maybe/maybe not) sitting in the room with the patient so they can examine the patient (efficient use of scare medical staffing resources, no?) and relay what they find, and the delays are interminable.  It takes at least twice as long (and probably close to three times) as long to get through the patients as it would in a normal clinic. 

And I'm lucky in that my speciality is relatively hands-off, most of the time and that examination of clinical signs forms a fairly small part of our diagnosis.  

It is certainly doable - even with current technology without the NBN.  Some  people do it over skype on a $20 webcam.  Fatter pipes and better resolution video will be nice, but isn't going to solve these problems - which are inherent with not having the patient sitting in front of you right now.

So let's look at the specific claims in the tweet that sent me off the handle. Minor nitpick:  $1000 per day is a commonly-quoted bed-day cost, and probably isn't far off the mark for a general hospital bed.  A bed requiring cardiac monitoring is going to be more expensive than that - for the equipment outlay but also for the ongoing costs and specialised staffing required to do something with the results of the monitoring.

It is a tenet of medicine that there is no point in monitoring something if you're not going to do something about it.   There are some heart rhythm problems that are not imminently life-threatening that are currently monitored as an outpatient using a Holter Monitor.  Note that they are already done as an outpatient.  The NBN isn't going to result in any significant bed-day savings at all.  Unless the patients want to wear them forever (and know how to put them back on after they have a shower etc etc), then they still need to attend a clinic to have them fitted and removed, so transmitting the data back to the cardiologist via the NBN really won't achieve anything at all given the monitor will be dropped back at the clinic anyway. A smaller number of patients have Loop recorders;  similar concept but implanted under the skin and intended to stay in for longer.  Wireless transmission of results would have some benefits, but the number of these devices is smaller than for conventional Holter monitoring.  

Some pacemakers or implantable defibrillators could provide similar telemetry data, but this is usually done in a pacemaker clinic, where the patients see their cardiologist at the same time.  Also, this is done as an outpatient - net bed-day savings:  Zero.

And finally are the group of people who need inpatient monitoring because of the possibility of a serious arrhythmia.  These patients usually come into hospital because they have had an event - a faint or palpitations - which can have a variety of causes or following a heart attack - when the risk of serious rhythm disturbance is high.  Part of the reason for monitoring in the first group is diagnosis - you want to monitor the heart rhythm to see what may have caused the event that brought the patient in to hospital. If it is a serious arrhythmia though, then the staff on the ward that are watching the monitor may need to do something.  This is also the reason patients get monitored after a heart attack.  Watching in case there is something that needs to be done.   If you're being monitored at home and you have a malignant arrhythmia that needs urgent treatment, then you're a long way from help.  If you're in coronary care, the nurses are in the same part of the hospital as you are.  Time to being defibrillated is the biggest factor in surviving a cardiac arrest due to ventricular tachycardia, so unless you have a paramedic sitting in his ambulance in your driveway, the NBN is no substitute for a CCU nurse and a cardiologist.

In the interests of balance, something that the NBN will help out with will be the transmission of radiology.  Modern scans (CTs, MRIs) produce a lot of data.  Current practice is for the patients to be given a DVD with the images on them when they leave the radiologists.    It will be a boon to be able to log on to the radiologist's website and download high-quality images quickly, rather than the scans on the DVDs (which all have proprietary readers and load slowly etc etc). So overall, I think that there will certainly be benefits of a nationalised fast broadband system to healthcare in terms of transmission of data, better quality videoconferencing and increasing the access of some people to some sorts of care.

But if you think it's going to slash bed-days or provide a panacea of comprehensive health care to people living in Oonah-Whoop-Whoop, or be a replacement for sitting in the room with your doctor, then you're talking crazy talk and you really should just stop.

Especially if you're trying to present yourself as a destroyer of misinformation about the NBN.