Will we ever bridge the gap?

Palm Island residents (Source: Bronte Sevil)

At 5:30 on the night of May 16th, Gary Jenkin gingerly makes his way from a surgery theatre in Phillip, Canberra into a more private room where his wife waits for him with a cup of milky Earl Grey at the ready. His right eye is patched and his white surgery hair net is stained with betadine. The local anaesthetic injected around his eye won’t wear off until the next day and he is left with an irritating numbness enveloping the right side of his face.

Doctor Randev Mendis is an ophthalmologist specialising in retina, macula and vitreous diseases and detachments – simply put, he is a vitreoretinal surgeon. Gary had been squeezed into Mendis’s busy Tuesday schedule and was under the knife by 5 o’clock to repair his torn retina. Gary has been through this before: the retina in his right eye initially tore in late 2016 and if it were not for his son Matthew’s quick decision to Google Gary’s symptoms on his iPhone, the 55-year-old electrician would have gone to work on a dusty jobsite which would have resulted in permanent damage to his eye.

The father of two lives in South Durras on the far South Coast of New South Wales where a population of around 300 enjoy regal beachfront views and an abundance of wildlife in their backyards. Perhaps the beauty of the small village compensates for the lack of medical facilities the “Durras crew” has access to, but Gary is starting to realise his optical health is taking a toll on his lifestyle.

“I’m allowed to do office work but I obviously can’t go into dusty, dirty environments at all, so I have to stay off building sites and I’m not allowed to drive for two or three weeks so I need a driver, I’m going to have to rely on Anne Maree”.

Gary’s wife, Anne Maree works part-time 20 kilometres down the road at Batemans Bay Hospital where she admits patients into the hospital. She also works at home to support Gary’s electrical company, Jenlec for a few days each week. Ironically, she will have to take time off work from the hospital over the next three weeks to care for Gary, creating an inevitable cycle that limits thousands of Australians’ access to healthcare. Although her position is part-time, Batemans Bay Hospital has replaced her for the next three weeks which only contributes to the fact that the Eurobodalla region is a District of Workplace Shortage (DWS).

Alongside a crucial shortage of medical workers, Batemans Bay and its surrounding communities are growing substantially every year. The relaxed lifestyle that the coastal town provides attracts thousands of retirees from metropolitan areas which has pushed the region’s current median age to 50. The Batemans Bay and Moruya Hospitals haveutilised their funds to provide medical services necessary for elderly residents meaning colonoscopies, gastroscopies and orthopaedictreatments are within 5 to 30 kilometres from their doorstep.

However, the retirees of Batemans Bay and middle-aged workers like Gary are forced to travel to metropolitan areas for many crucial health services. Travelling to Canberra, Sydney and Bega for services such as facial surgeries, ophthalmological treatment, long term rehabilitation and any kind of paediatric health has undeniably become the norm in coastal communities such as Batemans Bay which is perhaps why many seaside residents are unaware of their healthcare disadvantages.

Australia is famous for its diversification of unique nature, climate, landscapes and unfaltering multiculturalism. We are also one of the most geographically separated countries in the world with a surface spanning 7,000,000 square kilometres and the Australian Government has consistently battled to provide equal healthcare services to all Australians despite their place of residence.

Alongside the modern rise of technology, telecommunication has been adopted in simple yet effective ways by the Australian Government to ‘close the gap’ of healthcare inequality across rural, regional and metropolitan areas. Telehealth has been implemented by Medicare in the last ten years and is defined by the Department of Health as “the use of telecommunication techniques for the purpose of delivering telemedicine, medical education and health education over both long and short distances”.

The Department of Health labels any videoconferencing or video consultations that are subsidised by the Medicare Benefits Schedule as telehealth and depending upon the area of residence for Australians, individuals may or may not have their costs of teleconferencing to specialists and GP’s waived. Through use of an online map created by the Department of Health, Australians can discover the “remoteness” of their location according to government standards. Any individual who lives outside a major city area (anyone in an inner regional, outer regional, remote or very remote area) is eligible to receive subsidisedtelehealth. Anne Maree claims that the Batemans Bay Hospital uses telehealth for mental health patients to connect with psychiatrists and psychologists on a regular basis.

The telehealth service is undeniably helpful in the way that it encompasses Australians who do not have immediate access to medical advice from GP’s and specialists, howevertelehealth doesn’t come without its criticisms. Most of the country’s surface area is considered remote or very remote, meaning a third of the Australian population will receivesubsidised telehealth services, however, Michelle Bradbury, CEO of Central Coast Primary Care is critical of the lack of funding attributed to establishing telehealth across rural areas.

In 2012, the Department of Health and Ageing introduced a $20.6 million telehealth initiative which would be implemented alongside the first National Broadband Network (NBN) rollouts in rural communities, however, Bradbury suggests that the funding for this initiative was insufficient given the large population of Australians living rurally. Despite her discrepancies, Bradbury is adamant that telehealth makes healthcare more accessible in all Australian communities: “for rural and disadvantaged communities, telehealth technology improves patient health outcomes by delivering access to essential healthcare and service providers, which may not be otherwise afforded to such communities”.

Queensland’s tropical Palm Island, situated just north of Townsville amongst the Great Barrier Reef is considered by the Queensland Government as a third world country in regards to the overall living conditions of the island’s 3000 residents. The Department of Health maintains that Palm Island falls beneath the “remote” category and in 1934 and 1979, influenza andhepatoenteritis (Palm Island mystery disease) broke out however the illnesses remained largely confined to the isolated island.

In 2000, the Joyce Palmer Health Service was established and provides 15 beds alongside a primary level of acute care to the largely indigenous population. Palm Island’s health service does provide cost-free telehealth for all indigenous Australians for video consultations to Townsville and other metropolitan areas in Queensland and in an emergency situation the Royal Flying Doctors Service attends to the islanders. The Australian Government has provided a great amount of funding to Palm Island due to the uncommon indigenous majority and today they are still fighting to bridge the gap and achieve equal life expectancy between non-indigenous, Aboriginal and Torres Strait Islanders by 2030. Palm Island is perhaps a very rare example of the government working tirelessly to bridge the gap in an attempt to better the quality of life for indigenous Australians.

But it’s not just the government that have begun distributing healthcare via telecommunications. Many health professionals like Dr Angus Turner have taken matters into their own hands in an effort to bridge the gap. Dr Turner established a not-for-profit healthcare organisation, Lions Outback Vision when he returned to his hometown in Western Australia after years of studying in Perth and Melbourne where he excelled in studies of medicine and ophthalmology. “Telehealth has turned out to be a fantastic way for optometrists who live in rural towns to see patients for common conditions such as cataracts or glaucoma”, says DrTurner of Lions’ telehealth services.

The Lions Vision Van was established in 2016 by Dr Turner and Outback Vision and the vehicle currently circulates Western Australia twice a year to provide consultations and eye surgeries from Albany to Wyndham: “It has been successful at bringing state of the art equipment to the remote areas. Now the clinics provide equal access to technology available in the cities and there is less need for travel”. Prior to the emergence of telehealth, not-for-profit organisations such as Angel Flight connected patients to doctors and specialists by flying patients in emergency and non-emergency situations. As of 2017, Angel Flight has completed over 20,000 flights and is still operating tirelessly to bridge the gap.

The Lion’s Vision Van is no doubt fulfilling for doctors as it is useful and in some situations lifesaving for patients, however services such as these only cater for remote towns for a few days of the year. This would cause many patients to disregard their health issues purely because they know they have no way of being treated in the short-term. Gary’s first experience of a torn retina in December 2016 exemplifies an emergency situation being underestimated and ignored – if his son Matthew had not been in the car with him, Gary could have caused himself a permanent loss of vision.

So now we have come to a crossroads where more advanced informational technology needs to step in, and these technologies need to be available to every single person in Australia if we are to completely bridge this seemingly persistent divide between rural and metropolitan healthcare.

According to 2016 statistics from the ABS, 82 per cent of inner regional households have internet access while 79 per cent of outer regional, remote and very remote areas have internet access. Although Australia is falling behind in its ability to connect all to the internet, Australians are well ahead in their ability to access new telecommunication devices that allow internet connectivity such as smartphones. Google’s Consumer Barometer claims that 80 per cent of Australians use a smartphone while the percentage of those using computers has dropped from 86 per cent in 2012 to 80 per cent in 2016.

Telecommunication technologies are becoming more and more available to Australians who are largely inexperienced with technology. Smartphones and portable computers are opening Australians up to a whole new possibility of mobility and an ease of access to information and social connections. Smartphone applications (apps) are being downloaded every day and most of these apps are becoming less leisure-based and more informational and educational.

Healthdirect was established by the Australian Government as a healthcare company in 2006 and has subsequently expanded to provide similar services on smartphones via the Healthdirect app. Healthdirect provides health advice and indexes on ailments and medicines as well as a symptom checker search engine that allows users to submit their symptoms to gain an understanding of their illness in their own time and at their leisure. Alternatively, they maintain a website and hotline which provides 24-hour health advice for non-emergency situations.

Healthdirect has followed in the steps of many other health companies around the world such as WebMD , Mayo Clinic and Healthengine by expanding their services to a mobile device. The Royal Australian College of General Practitioners (RACGP) coins this method of receiving health advice as “m-Health” and suggests that this method of connection provides an immediacy and clarity of information-sharing and communication between health professionals and patients that has never before been possible.

Apps such as these have instigated a culture of do-it-yourself health meaning that patients no longer have to transport themselves to a doctor to gain health advice. Alongside this proliferation, there are over 200,000 health and wellbeing apps which suggest and promote healthier lifestyles by encouraging certain diets and regular exercise. Richard Hays, writer for the Australian Family Physician journal suggests that we are being drawn to a “gamification” through wearable technologies such as Fitbits and the Apple Watch which provide users with a reward system in which daily fitness goals can be set. Hays points out that mental health apps such as Headspace are significantly reducing the number of face-to-face appointments for many patients.

The transition to mobile technology is significantly reducing the cost of healthcare for millions of Australians because the necessity of travelling to a doctor for advice and even acute care has faded when patients can access advice from the safety and comfort of their own home. M-Health provides a continuity of advice and support if an internet connection is available – something that is necessary in communities such as Batemans Bay where specialists are only available a few days a week.

Healthengine is a leading service that allows Australians to book appointments and consultations, with over 1,500 visiting the website each day and perhaps thousands more visiting the app each day. Healthengine connects to general practices, dental practices and specialists across Australia, allowing potential patients to make appointments with any health clinic in the country. The app and website are designed to ensure their online booking system is as simplified as possible to help Australians connect to doctors immediately.

However, this definitive shift from physical to technological distribution of healthcare information has received widespread criticism from doctors and patients alike. There has been significant discourse from academics and news organisations that websites such as WebMD and MayoClinic are not providing correct medical advice and some are concerned that too many may be accessing this incorrect information regularly which significantly reduces the physical and mental health of patients.

Hays comments that “until legal frameworks, regulation and quality assurance improve, app purchases may be risky because of potentially significant differences in the interpretation of consent, confidentiality rights of children (dependant on age), access, rights to withdraw use and ownership of ‘added-value’ products”.

Companies like Apple, Telstra and Google have invested money into telemedicine to expand their own companies: Telstra has promised new apps to monitor healthcare and schedule appointments under a new offshoot of their brand, Telstra Health.

“For practitioners, it’s about smarter, more flexible collaboration. For patients, it’s about living longer, healthier lives. And for the nation, it’s about a more equitable, more sustainable future for all of us…Our initial offering is a set of innovative capabilities across the care continuum, but it’s how we connect the parts of the system that will define our success”.

Although healthcare advice apps and websites like WebMD may not contain academically-supported content, the premise of allowing patients to receive health advice from their own home would change the face of how medical information is disseminated across the country. Google provides Australians and millions of others around the world with a platform on which people can search for health-related topics and this is taking place in metropolitan and inner regional areas purely because people have the internet at their fingertips.

Almost 80 per cent of outer regional, remote and very remote areas of Australia have daily internet access meaning that if healthcare apps such as the government-funded Healthdirect were readily advertised in remote Australian communities, our country could close the healthcare gap in the next few years.

“New technology should be embraced as we work in partnership with patients to achieve better health outcomes. However, until proven safe and effective, some scepticism may be warranted about data accuracy and developers’ claims. There may be a need for central oversight, guidance and even Pharmaceutical Benefits Scheme style subsidisation to guide consumers and professionals.” (Richard Hays)

“People don’t want to travel. The problem is in rural areas; how much are you going to spend on health? We just don’t have the population base [in Batemans Bay] to have the services that Canberra have, that’s the fact of the matter” says Anne Maree. The experiences of Gary and Anne Maree exemplify that mobile technology is necessary for health - even in inner regional areas. Healthengine is used by Batemans Bay’s Health Service to streamline and simplify bookings to see GP’s, however for the outlying residents of the Eurobodalla, better apps need to be constructed to provide healthcare information and ultimately raise awareness of the importance of health in communities and demographics that are most at risk.

“Basically, if you have an emergency situation like mine you have to travel. I’d hate to live out in rural NSW, you see those ads on television about how far away it is to get to heart specialists and services like that. It’s scary if you’re way out there and running a farm, I mean that’s their lifestyle choice and work choices but when it comes down to it you’ve got to go out on a limb to keep your health in check and get the services you need to keep you alive”. (Gary Jenkin)

Telehealth has tremendously connected rural areas around Australia, however immediacy of information is starting to become more important in our modern, technologized world. Pairing government-funded telehealth with mobile services is an inevitable merge that will improve the quality of health for all Australians.

For more on Telehealth, visit: http://www.health.gov.au/internet/main/publishing.nsf/content/e-health-telehealth