Telehealth and the NBN have long been expected to revolutionise home-based healthcare in Australia. But could a scaled down version of the NBN affect that? AAA Technology Review reports.
Meet Des and Dorothy Poynter from NBN-connected Coffs Harbour, New South Wales.
Des, 69, has hypertension, high cholesterol and prostate cancer. Dorothy, 62, is borderline diabetic with high cholesterol and osteoarthritis.
To help manage their conditions, the pair have signed up to have their blood pressure, pulse oximetry and weight monitored daily via telehealth. Des says he is motivated to use telehealth to better self-manage his health and improve his clinical information for his GP. Dorothy says likewise and she also wants to better utilise health services.
Using their NBN fibre-to-the-premise (FTTP) connection, the Poynters are participating in Feros Care’s ‘My Health Clinic At Home’ pilot, which is funded by the Federal Government, originally under the guise of the NBN-Enabled Telehealth Pilots Program.
Aiming to demonstrate the benefits of the NBN, the program provided $20.6 million to nine projects to develop and deliver telehealth services to NBN-enabled homes. (See ‘NBN in action’ section below).
Telehealth and the NBN are expected to revolutionise home-based healthcare in Australia. By how much is not yet known but should become more apparent after these trials, coupled with government-commissioned independent cost-benefit analysis to determine the direct and indirect value in economic and social terms of increased broadband speeds. That report is due by mid-year.
The pilots, for their part, aim to demonstrate innovative, scalable and more accessible health services, reduced health related transport and hospitalisations, and collaboration and communication between consumers, carers and health service providers to improve quality of care and health outcomes.
But how does a revised NBN, under the Coalition Government, impact the effectiveness of telehealth delivery?
The original NBN under Labor, which was plagued by rollout delays and cost blowouts, saw around 93 per cent of Australian homes receiving FTTP, delivering download speeds of up to 1Gbps (gigabits per second) and upload speeds up to 400Mbps (megabits per second), and a combination of satellite and wireless broadband to the remainder delivering speeds of up to 25Mbps.
The Coalition Government’s new preferred option, as one of six put forward in December in a strategic review of the NBN it commissioned from NBN Co, the government-owned organisation building the network, involves an optimised multi-technology mix (MTM) scenario.
In the fixed line footprint it proposes using FTTP for 26 per cent of premises, fibre to the node (FTTN), such as the building or distribution point, for 44 per cent of premises, and an upgraded HFC, or cable TV network, for the remaining 30 per cent of premises. Alternative technologies such as FTTN might also be used in the fixed wireless and satellite footprint.
While the Coalition Government’s plan means fast broadband can be rolled out more quickly and at less cost than sticking with the original plan, as per its pre-election promise, it does not deliver the same level of speed or quality to as many homes.
It promises that by 2019, 91 per cent of premises in the fixed line footprint will have download rates of 50Mbps or more, and between 65 and 75 per cent will have 100Mbps or more. However, those homes getting FTTN, for example, would connect into the NBN over the existing copper telephone network, which has variable quality.
In answer to the question of how a revised NBN might affect telehealth, Des and Dorothy Poynter, and the other participants in the nine pilots, might be able to help. While the original scope of the pilots was for NBN-connected clients, delays in the rollout caused delays in the projects and problems recruiting clients.
Following requests by the pilot recipients, the rules were changed shortly after the Coalition Government came to power to allow any fit-for-purpose broadband connection to be used for the pilots. Organisations have gone ahead with testing telehealth using not only the NBN, but other technologies including ADSL, VDSL, and 4G mobile.
Common functions among the pilots are daily vital signs monitoring and high-definition video conferencing. Vital signs and questionnaire data is usually collected by the client every morning and automatically uploaded to the service provider for monitoring in one go. It is not sent in real time, the pilot representatives in this story tell AAA. Video, on the other hand, is in real time and requires a stable connection with minimum speeds in both directions, they agree.
Feedback from the pilots
Glenn Payne, chief information officer for Feros Care, says the Coffs Harbour-based pilot has given them the opportunity to compare the experience and quality of the NBN and 4G. “So far, NBN wins hands down,” he says.
The NBN FTTP service has enabled Feros to run a stable and consistent service into clients’ homes, Payne says. “We have had little to no issues with regards to service availability and the quality of the video conferencing has been outstanding.”
However, with 4G, he says they get good speeds capable of running the telehealth service, although it can be unreliable at times. “4G has been a great gap filler for us, but is not comparable to fibre as far as quality and stability of the service. We are working on the principal that when fibre becomes available in the client’s area we aim to cut them across as swiftly as we can.”
The policy evolution of the project to adopt “broadband that is fit for purpose” has made a lot of difference in getting on with the trial, says Suri Ramanathan, chair of the Aged Care IT Industry Council. The council is delivering a project in the Kimberley, WA, and Illawarra, NSW, regions in partnership with Silver Chain and IRT using a mix of fixed and wireless NBN connections and ADSL.
“That being said, members of the project fully support and accept the roll out of NBN as essential for future delivery of care services,” Ramanathan says.
There are no complaints about NBN services once connected for all trial components and in terms of the health monitoring functions they are testing, ADSL is so far proving adequate, he says. “The outcomes are still very good on ADSL2. All those remote and regional people don’t have to travel into the big towns. That’s the biggest item, particularly for older Australians.”
Testing of video conferencing on non NBN-connected homes has commenced but Ramanathan says they are not yet ready to divulge the results. However, the video education component, which they have been testing since the beginning, has been successful and they are finding ADSL+ more than sufficient for their needs.
High-definition video conferencing is “very hard to come by if you don’t have the NBN,” says Professor Branko Celler, project director on the CSIRO’s project monitoring chronic disease in older Australians. When doing high definition video conferencing you need to guarantee two-to- three- megabits in both directions synchronously, he says.
“I have a cable TV connection, it provides Foxtel and my internet connection, with the best modem available, and that is about the best you can get without the NBN,” Celler says. At best he gets 100Mbps down and 2Mbps up but says it is variable, making it difficult for high-definition video conferencing.
Most ADSL is half that, making it more difficult to do a high definition session but they can do normal definition with whatever the system will support, he says. “The quality may not be as good. The experience may not be as good. The questions is whether it is sufficient, and that is what we will be looking at.” He notes that high-definition photos – for a wound, for example – can be taken and sent as an image.
High-definition aside, quality is a key issue when looking at the proposed options of a future NBN utilising the existing copper network, Celler says, based on their experiences with the current trial. “We don’t need to have 100Mbps but we need to have a guaranteed quality of service.”
Choosing to connect patients without NBN access has been problematic, he says, adding it has required a lot of work in determining whether a client is connectable based on factors including the quality of the copper telephone line and how far they sit from the exchange.
“At present, with the variable quality and the variable distances and impacts of distances and the quality of the copper and all the rest of it, it can be a nightmare.” Sometimes the result is not being able to connect the patients, he says.
These concerns could continue under the proposed NBN for almost half of homes in the fixed line footprint. The strategic review did not address quality of service issues in its proposed MTM approach, or upload speeds that will be available for the different modalities.
These are two points raised by the Senate Select Committee on the National Broadband Network in its controversial interim report in late March, which raised concerns about the accuracy and reliability of December’s strategic review.
Among its recommendations is a revised strategic review providing details of two of the proposed options –the optimised FTTP rollout and MTM scenarios. It is also calling for consideration of broadband quality beyond download speeds, and the demand for attributes such as upload speeds and reliability in the residential and small business market.
Over at Feros Care, Payne says to offer a reliable quality of service, FTTP is the way forward. “The NBN has been a fantastic experience. Technology is evolving faster that what our current consumer internet is allowing. The faster and more reliable our internet the better we can future proof a sustainable telehealth experience for all clients,” he says.
Stelvio Vido, executive general manager, projects and business development at telehealth veterans RDNS, is a little more open-minded. He says their video conferencing has been delivered on ADSL terminals for some time and they find it adequate.
Looking at the proposed MTM scenario, Vido says based on their extensive experience with ADSL2 and the recent enhanced experience of the NBN, they are reasonably confident the sort of telehealth functions they would like to do are achievable, or could even be done with existing technology.
Fibre to the home is not necessarily required, Vido says, but when it becomes more commonplace either as a direct connection or as part of the connection that reaches the home, telehealth will only continue to be enhanced and indentured as a part of the community.
NBN in action
Originally funded under the NBN-Enabled Telehealth Pilots Program, the following is a snapshot of four of the nine commonwealth-funded trials underway aiming to demonstrate how fit-for-purpose broadband technology enables better access to high quality healthcare services in the home.
‘Home Monitoring of Chronic Disease for Aged Care’ by CSIRO:
Locations: Townsville; Penrith; Greater Western Sydney; Canberra and ACT; Ballarat and the Grampians; Launceston/Northern Tasmania. Participants: 150 test and 300 control patients. Technology: Telemedcare device, Samsung Galaxy 8 tablet. NBN; VDSL; ADSL2; ADSL. Speeds: NBN FTTP -> 25Mbps down/5Mbps up.
A unique feature of this project is the six sites have different models of care for managing chronic disease. The trials range from hospital-based chronic disease management programs to really low care, low touch HACC-funded community programs, says project director Professor Branko Celler. “Each one is meant to stand on its own two feet and we will be analysing the differences.” The medical-grade Telemedcare system is very advanced, he says. Monitoring functions include blood pressure, pulse oximetry, single lead ECG, spirometry, glucometry, weight, temperature in addition to clinical and wellness questionnaires.
‘My Health Clinic At Home’ by Feros Care:
Location: Coffs Harbour, NSW. Participants: 170+. Technology: Windows 7 Tablet. NBN FTTP (125 participants) or 4G. (45). Speeds: NBN FTTP -> 20Mbps down/10Mbps up. 4G -> on average 10Mbps-15Mbps down/25Mbps -30Mbps up.
This project targets seniors with COPD, chronic heart failure, unstable blood pressure and/or diabetes. “MHCAH technology prompts the clients daily to take their vital signs and answer a set of wellness questions, which are then transmitted to a secure triage website. Feros Care’s telehealth nurses then view readings and follow up action any interventions as required,” says Feros CIO Glenn Payne. Clients can make or take video calls to/from GPs, a telehealth nurse, case managers, health professionals and family. Group video calls with up to 16 callers are also possible, which Payne says has been used successfully for virtual group education and social group trials (see ‘Human factor’, page 14).
‘Integrated Home Telehealth’ by RDNS:
Locations: Tasmania; Victoria; Illawarra, NSW. Participants: 207+. Technology: Tunstall Samsung. NBN FTTP; NBN fixed wireless; ADSL2. NBN:ADSL2 ratio 25:75. Speeds: NBN -> 25Mbps down/5Mbps up. ADSL2+: generally 5-10Mbps down/>300kbps up.
This model integrates care by linking the patient, the GP, the visiting nurse service and the virtual nurse, says Stelvio Vido, RDNS executive general manager, projects and business development. “It is monitored out of our clinical contact centre in Campbellwell. That’s where we have got nurses in our contact centre on a 24/7 basis. They see the data that is coming down from the patient and then they can intervene. That intervention can range from just a call to the patient, sending one of our own nurses out or calling the GP.” The Samsung tablet supplied by Tunstall goes into the home and has a number of blue toothed peripherals connected to it, Vido says.
‘Serving Older Australians – a National Approach to NBN’ by Aged Care Industry IT Council with IRT and Silver Chain:
Locations: Geraldton, WA; Kiama, NSW. Participants: 120. Technology: Docobo HealthHUB, Samsung Tablet; NBN FTTP; NBN fixed wireless; ADSL2; Speeds: NBN Fixed wireless -> 25Mbps down/5Mbps up. NBN FTTP: 25Mbps down/10Mbps up. ADSL2/2+ -> 12Mbps down/1Mbps up.
The HealthHUB can measure things directly via bluetooth-connected peripherals whereas the user has to input the data into the tablet, says Suri Ramanathan, ACIITC chair. Research by Silver Chain has shown that when a person enters the data, they take more ownership of it whereas when it is sent via bluetooth, they have less ownership than the person entering the data. “For us as a sector we need our clients to take ownership of their own health and that is in fact not just older Australians but should be for all Australians.