This past summer, Dr. Peter Yellowlees, Head of the Department of Psychiatry at the U. of Queensland and Director of the Queensland Telemedicine Network, visited us in Kansas City. We took the opportunity to interview him.

TT: What brings you to the United States?

Dr. Yellowlees: I’m on a six-month sabbatical – taking the opportunity to travel and visit telemedicine programs in the U.S. and other countries. I plan to visit seven telemedicine programs in the US –Michigan, Texas, Kansas, Iowa, Oregon, Massachusetts and Washington, DC – where I’ll be meeting a lot of the major players in telemedicine and learning what they’re doing. After that, I’m going to England and to Malaysia. So far, I’m having a fantastic time. Everyone is being very nice and very helpful.

TT: Please describe the Queensland Telemedicine Network.

Dr. Yellowlees: The Network has been in operation for 2‡ years. It’s funded by the Queensland Health Department. We provide services across the entire state. The main bases are in Brisbane and Townsville, with 106 other sites. We have seven videoconferencing systems based in hospital and community service systems. We help these middle-range hospitals to provide services in rural areas by giving them access to the subspecialties and second opinion services of the big teaching hospitals in Queensland.

TT: How big an area and how many people do you serve?

Dr. Yellowlees: Queensland has 25% of the landmass of the U.S., with only 3‡ million people. Two and a half million of those people live in the southeast corner around Brisbane. The rest are widely spread out in towns of between 2,000 and 25,000 people. Our two bases in Brisbane in Townsville are 2000 km apart.

TT: What telemedicine services do you provide?

Dr. Yellowlees: We have the same functions as other telemedicine networks in Australia -- primarily to coordinate and organize telemedicine activities and to provide training in telemedicine for clinicians and for patients.

About half of our telemedicine capacity is used by psychiatrists, but the proportion is declining rapidly as other specialties use more. These include pediatrics, general practice, intensive care, ophthalmology, cardiology, dermatology, radiology, pathology, renal medicine, and emergency medicine.

We don’t have a central scheduling system. Scheduling is done locally just as it would be for an ordinary outpatient clinic. Because of heavy usage, a clinician may have to use any one of our seven videoconferencing systems, so we try not to have any one system "owned" by any one specialty.

Typically, a patient will be at the remote site with a local nurse or doctor and often with a family member. Information about the patient will already have been faxed through to the specialist. The specialist does a typical patient interview, but doesn’t just see the patient alone. It’s important that the patient has someone to follow through locally. The specialist will advise on what treatment should be given, but the local doctor does the prescribing. Our intention is not to take over patient care, but to support local providers.

TT: Why do you think that’s so important?

Dr. Yellowlees: We’ve tried other models, but I don’t think they would work in our context. We have strong local healthcare, and our tradition is that specialists support GPs. For us, telemedicine works the same way as the traditional system. We think it’s very important to have telemedicine mimic normal referral patterns.

Actually, I think that’s an important issue anywhere. You have to remember that normal referral networks have been in place for years, and they’re based on trust between clinicians. Telemedicine can increase the ability of clinicians to work well together, but it can’t supplant the traditional referral patterns. Over time, you may find different referral networks created by telemedicine, but initially we don’t attempt to do that. We see telemedicine as an adjunct tool for clinicians in their normal daily practice.

TT: What obstacles do you face?

Dr. Yellowlees: Money is huge issue for us in Australia, just as it is in the US. Most telemedicine services are provided through the state hospital system. Telemedicine is an extra service that is free for rural areas. But, it’s also an extra workload for the doctors who work in the state hospital system. It’s an extra burden for doctors who are already pretty pushed.

We also have a major private sector in medicine, but the only area there where telemedicine is used much is in radiology, where it is reimbursed [by the national healthcare system]. The federal government is considering reimbursing for other telemedicine services, but hasn’t yet agreed to that.

As in the U.S., we have a lot of concern that, if we make telemedicine services widely available, it will cause a cost blow-out. We know telemedicine is a good way to provide healthcare, but we’re not sure about the costs. My belief is that if there were more votes in rural areas of Australia, and the government therefore had to pay more attention to rural people, telemedicine would already be accepted for reimbursement. It certainly isn’t a quality-of-care issue.

We’ve done studies, and we know that telemedicine improves the quality of care. Obviously, since we’re comparing telemedicine to no services at all, it must improve quality of care. Everybody accepts that the quality of healthcare in rural areas will be improved – it’s a question of how much you have to pay for that improvement.

TT: Is there any local resistance to telemedicine in Australia?

Dr. Yellowlees: We’re probably one of the largest telemedicine systems providing regular services. As a consequence, we’ve spent a lot of time looking at how you manage a large system and how you implement telemedicine services within that system. I have a student working exclusively on that issue at the moment.

The major issue we’ve concentrated on has been the need for clinicians to own the system at the local level. As I said, we try not to have the teaching hospitals telling local people what to do. So our emphasis is on training and supporting local clinicians. Local clinicians can set up major barriers to the implementation of telemedicine if they don’t like the way it works. But most clinicians support the system if they understand how telemedicine can improve the healthcare they provide.

Telemedicine involves major changes for clinicians – learning new technology, new interviewing skills, new group skills and learning how to present themselves on TV. And it’s a slightly more threatening way of working because a nurse or another doctor is watching at the other end. For some doctors, that is difficult. For most, it is fine.

TT: What do you see for the future in telemedicine?

Dr. Yellowlees: I think that record sharing will be the next major development in telemedicine. Records won’t only be the domain of doctors- patients will have access, too. I think a lot of doctors will be outstandingly threatened by that, but I think it will lead to much better healthcare. Patients should have access to records, and they should be able to contribute to them. The only area where you might be concerned about this would be if there was an issue of dangerousness – but that’s relatively rare.

One of the beauties of this sort of approach is that it will inevitably lead to a much more open process. People just see telemedicine now as consultation. They don’t think about how it can lead to better healthcare generally or about how it can radically change the medical system and the healthcare delivery system and how it can empower patients. People don’t think far enough ahead – this really is a logical extension of what we’re doing now.

I’d love to see an integrated system that incorporates videoconferencing and the ability to pull up records and x-rays and other things to be shared with the patient. I’d also like to see a video record of a patient’s treatment included in the records that they could see. Patients often don’t appreciate how sick they were – so when they get better, they stop their medications and they stop taking care of themselves. Then they get sick again. Seeing how sick they were may encourage them to continue care.

At same time, patients should be able to become genuinely knowledgeable about their condition and treatment. I’d like for patients to be able to get good information from the system. Bad information on the Internet is a problem now. I think it’s one of the roles of a good doctor to ensure that whatever information the patient gets is accurate. I ask my patients to bring in the information they find so we can look it over.

There’s a lot of power in these systems to improve care by helping patients to make better choices.

Contact information:
Peter Yellowlees, MD
p.yellowless@mailbox.uq.edu.au
www.psychiatry.uq.edu.au - U of Queensland website