Rural eHealth paradox: It\'s not just geography!

Blackwell Publishing AsiaMelbourne, AustraliaAJRAustralian Journal of Rural Health1038-52822006 National Rural Health Alliance Inc.? 20061439598EditorialEDITORIALEDITORIAL

Aust. J. Rural Health (2006) 14, 95–98

Editorial Rural eHealth paradox: It’s not just geography!

Given current fiscal constraints, the greatest challenge confronting health authorities responsible for providing health services to the six million people dispersed across the 7.5 million square kilometres that constitute ‘rural’ Australia is how to meet the consumer need for access to quality health care in a cost effective way. The current inequitable provision of health care, exemplified by the fact that only 20% of the $2.3 billion spent on Medicare general practice rebates in 2002 was spent in rural Australia, contributes to poorer health status1,2 and can lead to suboptimal treatment and premature death.3,4 The current national discussion on eHealth and eCommerce makes it timely to consider the status and contribution of eHealth. eCommerce, the combined use of electronic information and communication technology (ICT) to transmit, store and retrieve digital data electronically for commercial and administrative purposes, locally and at a distance, can address the isolation and barriers to access to services and information faced by rural citizens. eHealth services, a subset of eCommerce, include electronic health record and information networks, telehealth and online services, personal and portable communication systems, health portals and decision support tools to assist prevention, diagnosis, treatment, health monitoring and personal lifestyle management. eHealth services can promote cost-efficiencies, facilitate coordination and integration in the health system, and improve equity of access to health services, education and information by rural patients, healthcare professionals, healthcare managers and authorities.5 eHealth can also strengthen the central role of the rural community hospital as a focus for intersectoral and inter-professional service integration and knowledge transfer between urban and rural services, and mainstream and specific purpose programs. Since the advent of the bush telegraph and the Royal Flying Doctor Service,6 numerous eHealth projects have been implemented across Australia,7,8 almost half of which are multistate or national and predominantly in

the primary health care setting. Table 1 shows the categories of eHealth applications currently in use. A constantly emerging theme is the suboptimal implementation and use of eHealth tools,7,9 with increasing evidence that this issue is more pronounced in regional and rural Australia.10,11 This is the rural eHealth paradox – rural areas stand to benefit most from eHealth but have the poorest infrastructure, resources, capacity and capability for successful implementation and uptake. Like the inverse care law, the paradox threatens the opportunity to meaningfully address the rural– urban differentials in workforce, health services and systems, and ultimately, health. Why is this the case? The contributing factors to the rural eHealth paradox extend beyond the logistical difficulties and costs associated with transcending vast distances. They include: 1. Policy and legislation Even with the National Electronic Health Transition Authority (NEHTA), which is tasked to oversee the implementation of the Australian national health information system, no explicit consistent national policy or appropriately funded implementation plan on eHealth, let alone rural eHealth, exists. Most jurisdictional ICT/eHealth policies and strategies focus on upgrading hospital systems rather than eHealth programs. The National Electronic Decision Support Taskforce (NEDST) described many of the more than 360 health ICT projects it examined as ‘. . . fragmented and uncoordinated, leading to problems of accessibility, scalability, duplication and lack of integration with existing systems’.7 This lack of national policy specificity and coordination is reflected in the inadequate eHealth infrastructure in rural health services and inefficient and unsustainable jurisdictional online information resources and telehealth programs. Benchmarks for adequate bandwidth and standards to enable costefficient and effective sharing of information have not been legislated for. The affordability and ability to connect reliably to the Internet and access information and services with reasonable speed are therefore not equitable between country and city. 2. Infrastructure and support Infrastructure is inadequate, less accessible and more expensive in rural environments than cities.

© 2006 The Authors Journal Compilation © 2006 National Rural Health Alliance Inc.

doi: 10.1111/j.1440-1584.2006.00786.x

The importance of providing appropriate, sustainable, high quality health care to all Australians, regardless of their socio-economic circumstances or geographical location, is paramount. Productivity Commission, 2005

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TABLE 1:

Current and potential eHealth applications in rural settings

Function

Examples of systems available

Service delivery and clinical care to improve quality and safety

• Electronic health records and prescribing applications: standalone or networked applications enabling information exchange and access to patient information from multiple access points • Electronic decision support including at-risk registers, prompts, reminders and recall applications • Remote patient monitoring, e.g. blood sugar, medications • Telehealth services as direct care, seeking 2nd opinions and referrals, e.g. telepsychiatry, telepathology, teleradiology, teleprescribing, teledermatology • Cyberhealth (online) services

Health service administration and management

• Transactions, e.g. ADT (Admissions Discharge and Transfer), ISIS (Inpatient Separation Information Summary) and numerous order entry, billing, accounting, payroll and roster applications • Management and service coordination and monitoring, including single point entry and seamless care pathways • Medicare payments and HIC Online

Education, training and support for health professionals and students networking

• • • •

Education, training and support for consumers and community

• Accessing Medicare payments and other services • Accessing support groups, including Call Centres • Accessing personal, clinical and public health information

Planning, research, evaluation and development (funders, managers and clinicians)

• Monitor needs analyses and service provision: data collection, aggregation and analysis, longitudinal and spatial monitoring, HIC data, burden of disease, e.g. AIHW, quality of care, and health outcomes • Population registers and reminder/recall applications

Online and distance education Student and teacher support: clinical placements, supervision and mentoring, professional QA and CPD – training, upskilling, support evidence based practice Professional networking – community without propinquity

AIHW, Australian Institute of Health and Welfare; CPD, Continuous Professional Development; QA, Quality Assurance.

Power and communication lines are unreliable and limited. Moreover, the effective use of eHealth applications requires new and different skills, particularly with managing the computer and eHealth resources to benefit patients. Compared with their urban colleagues, rural clinicians often have higher clinical and administrative workloads, have a higher patient/clinician ratio, cover a wider geographical area, have poorer access to specialist advice and institutional health care, have to handle a wider and more complex range of symptoms and treatments and have difficulty in recruiting and maintaining adequate numbers of professional clinical staff.12 Along with a lack of confidence in the benefits of eHealth, these factors are significant barriers to the adoption of eHealth. Skilled and reliable technical training and professional support must therefore be readily available, affordable and easily accessible to rural clinicians. 3. Clinical care models Inter-professional roles and perceptions are significant determinants of the use of online guidelines in

decisions about care,11 particularly in rural Australia where practice is more inter-professional and integrated than in metropolitan Australia. At time of writing, $130M has been allocated to the implementation of systems for a unique healthcare identification number for every individual healthcare professional and to develop a common language for health communications. A common language to describe the same concepts or activity is essential to avoid misunderstandings between patients and clinicians. Similarly, agreed reference clinical and information models are essential to underpin the design and implementation of eHealth applications across all settings of care. Overlapping and competing interests among the jurisdictions, online providers and other government and commercial stakeholders are also problematic, and contribute to cost-shifting and service duplication, for example, online teaching and learning like RRMEO (http://www.rrmeo.org.au) and RACGP Online (http://www.racgp.org.au). 4. Provider and consumer readiness for and acceptance of eHealth © 2006 The Authors Journal Compilation © 2006 National Rural Health Alliance Inc.

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The National EDS Taskforce (2002) identified confidence in eHealth, its impact on work processes, lack of skills in using eHealth, and concerns about medico-legal issues as key factors influencing user acceptance and adoption of eHealth.7 Clinicians will use applications if they are useful and relevant to their professional practice, easily incorporated into workflow and improve patient care, such as prescribing systems with drug–drug and drug-disease interaction prompts.11,13 Similarly, consumers will use applications like ‘online health advisors’. These tools should enhance the patient–clinician relationship, not detract from it. Issues associated with privacy, security and duty of care across state boundaries must be addressed, issues that are increasingly important as more sensitive genetic information become available and used in health care. User friendliness, accessibility and affordability of eHealth are especially important in order to avoid further marginalising existing socioeconomically disadvantaged groups with a digital divide. So what are the solutions to this rural eHealth paradox? This ‘inverse care’ paradox highlights the need to systematically examine and improve the take-up of eHealth as a means of improving delivery of health services. Adequate funding is important but, without a national strategic approach underpinned by a research and development (R&D) framework to continually monitor and improve the eHealth systems, the rural– urban inequities will not be addressed. Understanding the rural and remote context remains central in determining how best to deliver health care services and the role that eHealth can assume in monitoring rural–urban differentials in health status and evaluating the impacts of health services on both the determinants and outcomes of health. This R&D framework must address technical (system architecture and communication standards), terminological (semantic and syntactic), change management, technology diffusion, clinical, epidemiological, health services, social and economic issues. eHealth programs and applications should focus on improved technology diffusion, cost-efficiencies, health care processes in prevention and disease management, patient health outcomes and decision making by clinicians, managers and policy-makers in the metropolitan, regional, rural and remote settings. Some R&D questions could include: • What are the optimum technical and semantic interoperability standards for a cost-effective eHealth system in (rural) Australia? • What change management and technology diffusion strategies work best where? © 2006 The Authors Journal Compilation © 2006 National Rural Health Alliance Inc.

• How does eHealth make a difference to clinicians and contribute to improved health outcomes, health determinants and economic gains in rural environments? • How might eHealth improve access and equity of health care for rural Australians, particularly the indigent and lower socioeconomic groups? • What are the different rural–urban requirements for resources, infrastructure, training and support programs and eHealth workforce? • What are the requirements (for individuals and organisations) to ensure a reliable, confidential and cost-effective eHealth system for rural Australians? • How do we facilitate the diffusion of eHealth into the rural workforce? How ready is rural society for information technology insertion? What are the market relationships among the actors in the informatics and telecommunication fields? • What useful, relevant, safe and effective eHealth applications assist to overcome the rural eHealth paradox? These interrelated issues require a collaborative approach between all levels of government, universities, health authorities, private industry, health professions and consumers within the framework of national eHealth standards and benchmarks for ethical research and practice. There is little doubt that eHealth will become increasingly important in ensuring the effective delivery of quality health care to residents of the many small rural and remote communities dispersed across Australia. In the words of the European Information Society, eHealth is ‘. . . today’s tool for substantial productivity gains, while providing tomorrow’s instrument for restructured, citizen-centred health care systems and, at the same time, respecting the diversity of our multicultural health care traditions’ (Europa: http:// europa.eu.int/information_society). S.-T. Liaw University of Melbourne, School of Rural Health J.S. Humphreys Monash University, School of Rural Health

References 1 Australian Institute of Health and Welfare (AIHW). Health in Rural and Remote Australia. Canberra: AIHW, 1998. Report No.: AIHW Cat. No. PHE 6. 2 Sadowsky K, Hagan P, Kelman C, Liu C. Health Services in the City and the Bush Measures of Access and Use Derived from Linked Administrative Data. Canberra: Commonwealth Department of Health and Aged Care, 2001. Report No.: Occasional Paper No. 13. 3 Hall S, Holman D, Wisniewski S, Semmens J. Prostate cancer: socio-economic, geographical and private-health insurance effects on care and survival. BJU International 2005; 95: 51–58.

98 4 Jong K, Smith D, Yu X, O’Connell D, Goldstein D, Armstrong B. Remoteness of residence and survival from cancer in New South Wales. The Medical Journal Australia 2004; 180: 618–622. 5 Humphreys J. Health service models in rural and remote Australia. In: Wilkinson D, Blue I, eds. The New Rural Health. South Melbourne: Oxford University Press, 2002; 273–296. 6 Idriess I. Flynn of The Inland. Sydney: Angus and Robertson (Publishers) Pty Ltd., 1932. 7 National Electronic Decision Support Taskforce. Report to Health Ministers: Electronic Decision Support in Australia. Canberra: National Health Information Management Advisory Committee, 2002. 8 National Electronic Health Records Taskforce. A Health Information Network for Australia. Canberra: Commonwealth of Australia, 2000.

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9 Liaw S, Schattner P. Electronic decision support in general practice. What’s the hold up? Australian Family Physician 2003; 32: 941–944. 10 Westbrook J, Gosling A, Coiera E. Do clinicians use online evidence to support patient care? A study of 55,000 clinicians. Journal of the American Medical Informatics Association 2004; 11: 113–120. 11 Liaw S, Pleteshner C, Deveny E, Mulcahy D, Guillemin M, Arnold M. An Evaluation of the Clinicians Health Channel (2000–3). Final Report to the Office of the Chief Clinical Advisor, Victorian Department, of Human Services. (Commercial in Confidence). Melbourne: Victorian Department of Human Services, 2003. 12 RDAA Rural Doctors Association of Australia. Viable Models of Rural and Remote Practice. Canberra: RDAA, 2003. 13 Liaw S, Kerr S. Decision support needs to be evidencebased. British Medical Journal 2004; 328: 1566.

© 2006 The Authors Journal Compilation © 2006 National Rural Health Alliance Inc.