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Clinical Practice

Health online: the future isn't what it used to be

Over the next 10 years, the healthcare system will change to focus more on preventive medicine and healthcare in the home, with fewer doctors and a new class of home healthcare providers. Healthcare professionals need to debate how best to manage these changes.

Peter M Yellowlees and Peter M Brooks

MJA 1999; 171: 522-525

Introduction - Changing information presentation - The effects - The solutions - References - Authors' details
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Introduction Over the past 30 years the framework in which doctors and other healthcare professionals practise has changed relatively little in comparison with the enormous changes seen in transport, manufacturing and telecommunications. While many doctors and health service managers prefer to ignore the extraordinary changes outside of the health system, they do so at their peril. Healthcare will be very different by 2010; the focus will be on the patient at home rather than the provider in the institution.

There are three major drivers for this change.1 The first is the economic imperative to restrain healthcare costs in a setting of an ageing community and escalating costs of institutional care and technology. Our present model of care primarily focused on institutions, be these hospitals or related step-down facilities and nursing homes, is not sustainable. In Australia, we already spend more than $21 billion per year on institutional (hospital and nursing home) care. We have to explore ways of reducing this cost.

The second is increasing consumerism, and the evolution of the "informed patient". As the "baby boomer" generation ages it will be increasingly concerned about its own welfare and will focus more and more on health. Every social issue that this generation has touched has changed radically, and there is no reason why healthcare should be exempt. The dynamic, yet often self-centred, approach by the baby-boomers is likely to be translated into a much stronger push for home healthcare.

The third is the extraordinary changes in communication technology, and the evolution of the Internet. Knowledge has never been as important and as accessible as it is today -- it is now one of the economic cornerstones of our society. The distribution of knowledge is occurring at a remarkable pace via the Internet, as well as through multiple other media outlets. For some years, clinical care has been increasingly delivered electronically via telemedicine, as well as telephonically. Australia is at the leading edge of these developments.2,3


Changing information presentation
Before we can benefit from the new technologies (see Box), we have to solve the problems of information quality and information overload, especially on the Internet.9 A variety of sites are being developed as quality health information portals, such as the National Library of Medicine in the United States,10 HealthInsite in Australia,11 and Omni in the United Kingdom.12 In addition, approaches are being developed to allow clinicians and patients to better assess the reliability and validity of health information.13 A more comprehensive Internet classification and coding system using metadata, as well as the development of sophisticated search engines, needs to emerge as a long term solution for this important problem.9 Only then will doctors be able to effectively obtain good quality decision support information within the time and process of a typical consultation.

Within the health industry there have been enormous strides in the past five years in the development of electronic patient records, many using Internet protocols. The health system is, unfortunately and inevitably, still replete with many different types of information systems, most of which have been focused on financial and administrative applications. The challenge in the future will be to get all of these "legacy" systems to talk to the new Internet-based systems. Fortunately, Australia is well placed in this respect with the recent funding by the Federal Government of the Cooperative Research Centre for Distributed Systems Technology,14 which has a long term research program with the Centre for Online Health at the University of Queensland.15 There are many related activities at Monash University,16 the University of New South Wales,17 and in private industry. The national approach taken by the Collaborative Health Informatics Centre18 is greatly assisting the integration of the health and information technology industries.

The effects We have a good idea of the illnesses and diseases that will be most prevalent and will cause the greatest disease burden by 2020.19 These are chronic cardiac, respiratory and psychiatric diseases, as well as road traffic accidents. The cardiac, respiratory and psychiatric diseases are all highly amenable to the provision of long term home care, while clearly a much more active approach to prevention and education is required to reduce the impact of road traffic accidents.

A changing paradigm
If we assume that by 2010 health information will be available in the homes of most Australians, and certainly on every health professional's desktop, then what will be the effects? The health system is already moving away from supporting episodic care to supporting continuity of care, and from a service-provider focus to an informed-patient focus. Increasingly, our past individual approach to treatment will be overtaken by the need for team approaches, underpinned by evidence and outcomes, clinical pathways, and guidelines. "Wellness promotion" will be seen as being more important than illness treatment. There will be a move away from institutional care to community care and to the development of the shared, distributed electronic patient record. Hospitals and health departments will make the shift from being autonomous, slowly-growing empires to becoming fluid and rapidly changing enterprises, as has occurred in industry.

Therefore, there will be a need, quite simply, for fewer hospitals and more home care and community support services. Figure 1 shows a mock-up of how a patient's Web browser might look during an online consultation with a general practitioner. This patient-accessible electronic home care record system would allow instant contact with a range of healthcare professionals, information sources and other health services in an electronic distributed environment. The system will involve telemetry, monitoring, video links and automatic ordering systems, all delivered via Internet2. The entire health system will be focused on the patient at home (Figure 2) rather than on providers and institutions. If we can reduce institutional care by just 10%, over $2 billion per year will be made available for redistribution.

The traditional doctor-patient relationship will alter, being driven much more intensively by patients. The doctor's role will become more advisory, analytic and interventionist. Doctors will need to be experts in assessing information from many different sources and in clinical reasoning, particularly for patients requiring more than a guidelines-and-pathways approach to care.

Healthcare education will also be radically different. Medical schools and other health education institutions need to be thinking today about educating clinicians to work within a distributed, primary care focused environment.20,21 If we are correct in our predictions, there will be a need for fewer doctors beyond 2010. Not only will so much of our present-day medical content, knowledge and expertise be less important, but a group of highly skilled home healthcare professionals will exist, probably evolved from today's nurse practitioners. These healthcare providers will have prescribing and other treatment roles for patients being treated within pathway and guideline protocols.

The changes will not stop there. There will also be massive opportunities, particularly for Australia, as it may be possible for Australian physicians to provide very much cheaper electronic healthcare into the US than is available locally within that country, if only because of differences in the cost of living and the strength of the dollar. It is more likely, however, that electronic healthcare will be provided in three main time zones (Figure 3), as it is highly unlikely that a doctor in, say, Australia will be prepared to consistently get up in the middle of the night to treat a patient in, for instance, Saudi Arabia or Brazil.

The introduction of global electronic physicians and virtual healthcare systems will raise many important cultural, ethical, legal and legislative issues. These include, for example, the need for international medical registration and medical defence systems, the development of global information and security standards for the Internet, more flexibility in drug licensing across countries, and the need to integrate Eastern and Western styles of medicine when working across cultural boundaries.


The solutions
What are the implications of these changes for the present Australian healthcare sector? What should be done to prepare for this scenario? The following are suggestions.

Cultural and political understanding and attitudes: There is a need for increased awareness of the importance of communications technologies in healthcare. Most global companies assume that 5%-10% of their budget will be spent on communication and information technologies. Research into distributed healthcare, both clinical models and technical solutions, is likely to be just as important as biotechnology in improving our national health profile. The clinical and information management issues are more important than, and have to drive, the technological changes. Once government makes a commitment to the changes looming in the near future, there will be the opportunity to create the necessary cultural and social changes required nationally to enable us to move to a future where information technology underpins healthcare delivery.

The healthcare environment: There is a need for urgent, widespread debate about the future of healthcare, about the respective roles of doctors, patients, and other healthcare professionals, and about how best to transform a hospital-focused health system to one centred on patients and home care. If change is not guided from within the health system, it will certainly be enforced by external global and national factors.

Technological requirements: There is a need to link the many existing computing systems into an Internet-based future. The necessary technological and information-based research and development programs must be focused on the development of user-friendly interfaces for patients of all ages, as well as for clinicians, and will involve the development of electronic clinical care protocols, whether these be delivered in real time, or by "store-and-forward" email, video mail, video conferencing, telephony or other methods. Specific projects need to be developed in home care, in wireless and collaborative environments, and in the development of improved electronic records. Australia needs closer links to the Internet2 consortium and to the exciting opportunities occurring in other countries, such as the Multi Media Super Corridor in Malaysia.22 Henry Ford, around the start of the 20th century, was quoted as saying that "history is bunk". While we believe strongly that history is of great importance, we also have to be well aware that the range and variety of changes confronting the world at present are greater, and are occurring more rapidly, than has ever been the case in the history of mankind. To quote Dr Rick Satava, an eminent surgeon with NASA: "The future isn't what it used to be."23

References
  1. Yellowlees P. Therapy online. Kansas: Telemedicine Today, 1999.
  2. Queensland Telemedicine Network. Queensland Health. <http://www.health. qld.gov.au/qtn/home.htm>. Accessed 18 October 1999.
  3. Yellowlees PM, Kennedy C. Telemedicine: here to stay. Med J Aust 1997; 166: 262-265.
  4. University Corporation for Advanced Internet Development. The Internet2 Project. <http://www.internet2.edu/>. Accessed 18 October 1999.
  5. Cairncross F. The death of distance. How the communications revolution will change our lives. Boston: Harvard Business School Publishing, 1997.
  6. Virtual Collaborative Clinic. <http://www.nren.nasa.gov/vdoc.html>. Accessed 5 October 1999.
  7. Graphics Visualisation and Usability Center, College of Computing, Georgia Tech. Virtual Reality Exposure Therapy. <http://www.cc.gatech.edu/gvu/virtual/Phobia/>. Accessed 5 October 1999.
  8. Van Houweling D. Distributed Education. 1998. Telecon '98 Conference, Anaheim, California.
  9. Appleyard R. Enhancing internet medical document retrieval with 'medical core metadata'. Health Information on the Internet 1999; 10: 6-8.
  10. United States National Library of Medicine. <http://www.nlm.nih.gov/>. Accessed 18 October 1999.
  11. HealthInsite. Commonwealth Department of Health and Aged Care. <http://www.healthinsite.gov.au/>. Accessed 18 October 1999.
  12. OMNI: Organising Medical Networked Information. <http://omni.ac.uk/>. Accessed 5 October 1999.
  13. Discern Online. <http://www.discern.org.uk/>. Accessed 12 October 1999.
  14. Distributed Systems Technology Centre. <http://www.dstc.edu.au/>. Accessed 5 October 1999.
  15. Centre for Online Health. University of Queensland. <http://www.coh.uq.edu.au/>. Accessed 5 October 1999.
  16. Centre of Medical Informatics. Monash University. <http://www.monash.edu.au/informatics/>. Accessed 5 October 1999.
  17. Biomedical Systems Laboratory. University of New South Wales. <http://www.bsl.unsw.edu.au/>. Accessed 5 October 1999.
  18. Collaborative Health Informatics Centre. <http://www.chic.org.au/main.html>. Accessed 5 October 1999.
  19. Murray CJ, Lopez AD, editors. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Harvard School of Public Health, 1996.
  20. Carlile S, Sefton AJ. Healthcare and the information age: implications for medical education. Med J Aust 1998; 168: 340-343.
  21. Coiera E. Medical informatics meets medical education. Med J Aust 1998; 168: 319-320.
  22. Mohan J. Malaysia's Telemedicine Vision and Initiatives. 1997. Telemed Asia '97 Conference, Kuala Lumpur, Malaysia.
  23. Satava RM. Telemedicine and virtual reality. American Telemedicine Association Annual Meeting, Salt Lake City. 17-21 April 1999.

Authors' details Faculty of Health Sciences, University of Queensland, Brisbane, QLD.
Peter M Yellowlees, MD, FRANZCP, Professor of Psychiatry, and Director, Centre for Online Health;
Peter M Brooks, MD (Monash), FRACP, Professor, and Executive Dean.

Reprints will not be available from the authors.
Correspondence: Professor P M Yellowlees, Department of Psychiatry, University of Queensland, K Floor, Mental Health Centre, Royal Brisbane Hospital, Brisbane, QLD.
P.YellowleesATmailbox.uq.edu.au
http://www.coh.uq.edu.au

©MJA 1999
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Changing information technologies

The technical ability to obtain high quality health information in the home or on the doctor's desktop depends on two things: bandwidth and accessibility. Both are on the point of being transformed to make massive amounts of information easily available to the clinician. The bandwidth issue relates to the development of Internet2 by a consortium of about 200 partners, mainly in North America, and including over 130 universities and more than 40 commercial concerns. Internet2 is expected to be between 100 and 1000 times more powerful than the present Internet. It will use much more efficient methods of information packaging to send more information down an equivalent-sized channel in a given time. This will enable a whole new generation of applications and has the potential to transform our lives in ways we cannot yet imagine. 4 The issue of accessibility to information is also being resolved within First World countries, although it is crucial to note that in 1999 two-thirds of the world's population still do not even have access to a telephone. 5 There are already over half a million kilometres of fibreoptic cable connecting cities and countries around the world. This will double within the next five years. By the end of 2000, it is expected that the latest of many intercontinental data links, a massively powerful fibreoptic cable weaving from Germany through the Mediterranean, across south-east Asia and on to Japan and Korea, will be installed. Simultaneously, greatly improved interactive satellites are being launched. There are now more than 200 such satellites in low earth orbit, acting like mobile phone towers or repeaters above the earth. Within five years, it is likely there will be more than 1000 such satellites, providing accessible global coverage. Improved bandwidth and accessibility will provide the opportunity to radically change the way we work and conduct business. We will be able to develop fully digitised libraries that include comprehensive video and audio collections, as well as develop cyberclinics such as the NASA-sponsored Virtual Collaborative Clinic. 6 There will also be collaborative virtual research laboratories enabling "tele-immersion" - the ability to move inside space, inside the human body and into virtual reality situations. Virtual reality scenarios, where the patients move into a virtual world as part of their treatment process, are already being used to treat patients with specific phobias of heights and spiders. 7 Scenarios also exist to allow surgeons to immerse themselves within a virtual middle ear, and teach the anatomy, pathology and surgery of the ear from within that organ. 8
Glossary

Bandwidth: The data transfer rate of an electronic communications system.

Internet: An electronic communications network that connects computer networks and organisational computer facilities around the world.

Internet protocol: The communications methods used for the Internet.

Metadata: Data about data, such as what field the data relate to, who compiled the dataset, or how the data are formatted.

Telemetry: Measurement of data and transmission to another site for storage or analysis.

Virtual reality: An artificial environment which is experienced through sensory stimuli (as sights and sounds) provided by a computer and in which one's actions partially determine what happens in the environment.
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Figure 3
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