This Insights Article is the fourth of four international case studies published to support the mHealth Solutions Insights Guide no. 2, Evaluating mHealth adoption barriers: Politics & Economics.
Clinical background: high stakes
In Australia, cardiovascular diseases kill one person nearly every ten minutes, according to government estimates. Managing these conditions costs the country's healthcare services more than $5.5 billion every year.
After hospital treatment for an event such as a heart attack it is best for patients to complete a six-week rehabilitation program, helping them to return to an active life and to prevent a relapse. However, recent data shows that just 11% of patients across Australia are referred to rehabilitation programs at hospital discharge. In Queensland and New South Wales, fewer than 20% of all eligible patients complete a rehabilitation program, and similarly low rates have been reported elsewhere.
There appears to be a range of reasons for this. Patients may be in work, or have responsibilities at homes as carers, and many appear to find weekly travel to a clinic difficult.
The Brisbane-based Australian e-Health Research Centre (AeHRC) aims to improve this with its Care Assessment Platform (CAP), a suite of mHealth tools including smartphones, web-services and biosensor technologies currently being tested at hospitals in Queensland.
Patients are given a Nokia N96 smartphone with an integrated accelerometer, step counter software and a diary application. They also receive a blood pressure monitor and weight scales. The patients maintain the diary with details such as exercise, stress levels and sleep patterns, smoking and alcohol use, diet, and their weight and blood pressure levels.
Mentoring and teleconferences take place via phone, and motivational text messages are sent to patients daily. Pre-loaded educational multimedia content guides the patient through the program. As with more traditional approaches the patient receives a face-to-face assessment after six weeks.
Preliminary results show significant improvements, with 25% of patients in the mHealth trial withdrawing, compared with 42% in a regular program over the same time period. AeHRC is now also developing mHealth applications promoting healthier lifestyles for rural/regional communities and for managing chronic pulmonary diseases.
The Road to "Connectedness"
The state of South Australia is exploring the idea that "connectedness" is a key component of health and wellbeing for citizens, and that mobile phones have a role to play in supporting it.
In 2008, as part of its Digital Technology Health Lens project, Flinders University in Adelaide was commissioned to explore digital connectedness among socially and economically disadvantaged groups in the state.
Focus groups revealed strong correlations between the use of technology and education, literacy, employment status, home ownership and income. Even where access was possible its use was limited by individual capability, digital literacy and confidence, and insufficient financial resources. People often withdrew from using the technology rather than risk embarrassment at their lack of skill or possession of the latest gadget.
The second phase of the study explored how people's interaction with digital technology may be encouraged and supported, and identified barriers to greater use of mobile phones.
Typically, within disadvantaged groups there is limited use of mobile broadband services. Reasons included real and perceived costs, lack of awareness about online content and access mechanisms, lack of skill and confidence in using the technology and complexities inherent in both the technology and the contract options available.
The project explored the benefits offered by mHealth and how it might be made more attractive to participants. SMS text alerts emerged as a possible starting point: people could readily see the value of receiving SMS appointment reminders from dentists and doctors, for example.
Many participants already received commercial text alerts and habitually ignored them as "junk mail". In contrast, government alerts were seen as "important" and would be opened if they were identified clearly on incoming messages. Alerts on important topics may be a way to introduce users to online services through embedded links, but it must be made clear whether this will cost the recipient any money, the research suggests.
From Rugged Beginnings: "The Tyranny of Distance"
Australia was among the first countries to grasp the potential of telemedicine – and before the age of the internet. Government archives record the case of a postmaster in Halls Creek Western Australia who, in 1917, followed instructions telegraphed in Morse code by a surgeon in Perth to perform an operation on a stockman who had sustained serious internal injuries after falling from his horse.
From these rugged beginnings the country has remained committed to seeing technology "overcome the tyranny of distance" for people living in the bush. Since small-scale healthcare ICT projects emerged in the 1990s the national government has sought to develop a comprehensive and coherent approach across the country, with varying degrees of success. At a national level, health policy is the responsibility of the Ministry for Health and Ageing, while states have developed their own centres of expertise.
Queensland in particular is a leader, being home to the Australian e-Health Research Centre (AeHRC), a joint venture between the Queensland Government and the Commonwealth Scientific and Industrial Research Organisation, Australia's national science agency. With outposts in New South Wales, Victoria and South Australia, AeHRC has a national reach and a focus on technology research.
The other key player is the National e-Health Transition Authority (NEHTA), which was formed in 2004 with a remit to develop and promote the infrastructure needed for a "joined-up" approach to healthcare ICT: a shared set of technology standards, clinical terminology, and methods of identifying patients and service providers.
In policy terms, a significant recent development was the launch of the National e-Health Strategy in 2008. This renewed commitments made by previous administrations to a strategic approach and a plan for national collaboration and coordination. It also faced the task of responding to research commissioned by the Government and conducted by Deloitte that found Australia lagging behind other countries in terms of investment in healthcare ICT.
Importantly, it committed the government to engaging citizens more fully on healthcare ICT, a process that will be vital for driving take-up of electronic health records. In the government's 2010–11 Budget $466.7 million was set aside for the Personally-Controlled Electronic Health Record project. The aim is to make the records available to every Australian who chooses to have one from July 2012.
The potential for healthcare ICT to overcome the "tyranny of distance" also requires a modern broadband network covering most of the country, an infrastructure Australia has lacked until recently.
In 2011 an OECD report ranked Australia 21st out of 34 countries for fixed broadband subscribers, finding that Australians typically pay more for broadband than many countries. In terms of average subscription prices, Australia is 3rd most expensive of 24 countries for low-speed connections, for example.
The country aims to change this with the rollout of the National Broadband Network (NBN), replacing the mainly copper-based network owned by Telstra. NBN is a high-speed network comprising three technologies – optic fibre, fixed wireless and satellite.
It is expected that by 2021 93% of Australian homes, schools and businesses will have access to NBN through fibre to the premises technology, capable of providing broadband speeds of up to one gigabit per second, while 7% of premises will use fixed wireless and satellite technologies by 2015, providing peak speeds of 12 megabits per second.
Australia's National Digital Economy Strategy, published in May 2011, sets out eight goals including improvements in health services and care for the aged. Specifically, that by July 2015 some 495,000 telehealth consultations will have been delivered, providing remote access to specialists for patients in rural, remote and outer metropolitan areas. By 2020, the strategy says, individual electronic health records will be available to 90% of high priority Australians such as older people, mothers and babies, those with a chronic disease or their carers; and telehealth consultations with remote patients will be provided by 25% of all specialists.
NBN is set to be a key element in achieving these goals, providing an infrastructure that enables homes, doctors' surgeries, pharmacies, clinics, care facilities for the aged and other health professionals to connect to affordable and reliable broadband services.
Specifically, the strategy seeks to develop and test services which demonstrate how:
- Telehealth services can be delivered to the home and become more accessible in regional, rural, remote and outer metropolitan areas Citizens can collaborate more effectively with carers and healthcare providers to improve quality of care and health outcomes, and reduce social isolation
- Telehealth can improve early identification of health issues and reduce unnecessary hospital visits
- Telehealth services are scalable and able to provide an increased volume of care without a proportional increase in costs
- Regional or location dependent skills shortages in the health workforce may be mitigated
- Communication during emergencies could be improved
To stimulate migration to the new network, the government has launched the NBN Enabled Telehealth Pilots Program. Running from July 2012 until June 2014, up to $20.6 million in funds will be available for pilot projects to develop and deliver telehealth services to homes with a focus on aged, palliative or cancer care services. It is expected that funding for individual projects will be around $1 million to $3 million.
Funded projects are expected to be sustainable and scalable beyond the project sites and potentially to a national level as the NBN rollout progresses. By providing better access to health services to homes within NBN early release sites, the program is expected to investigate and demonstrate opportunities for future telehealth services and the business case for doing so.
In the process, Australia's dream of "connectedness" for all citizens of this highly dispersed nation is moving closer to reality.