How do you ensure that a population as large as 1.3 million, spread across an area of 650 000km² receives the healthcare services they need?

For the state of New South Wales (NSW), the answer is an ICT infrastructure which is reliable, secure and available. Close to a quarter of NSW’s population reside outside the state’s major cities of Sydney, Newcastle and Wollongong. Residents in the regional, rural and remote communities require equal healthcare services their city counterparts enjoy.

One of the masterminds behind enabling world class and seamless healthcare services for this demographic is Dr Zoran Bolevich. The Chief Information Officer of NSW Health and Chief Executive of eHealth NSW has recently been ranked fourth in the third annual CIO50 list. The list recognises 50 leading technology and digital chiefs from across Australia’s private and public sectors who pioneer organisational innovation and transformation.

Under his leadership, the eHealth Strategy for NSW Health: 2016 – 2026 was delivered. The plan supports the digital transformation of New South Wales’ public health system. A project of mammoth undertaking, it includes a Rural eHealth Program. Catering to Australia’s largest public health system, it provides ‘anywhere, anytime’ access to patient records for rural and remote clinicians. It is truly testament that telemedicine can lead to better healthcare outcomes.

OpenGov Asia had the opportunity to chat with Dr Zoran at the Asia Pacific MedTech Forum 2018, where he was a speaker. He shared with us how his team used telemedicine to overcome the challenge of distance in delivering and receiving quality healthcare.

This article is the first of a two-part article. Click here to read the second.

Going the Distance

NSW is a geographically diverse and massive region. Although there is a good number of hospitals in the state, the 228 facilities are spaced out across six rural Local Health Districts (LHDs). Close to half of these facilities are in Australia’s outback.

“Typically, rural hospitals do not have the same number of clinical staffs compared to larger hospitals. Furthermore, they may not have the different types of specialists found in larger cities or tertiary hospitals. Some of the rural hospitals are even run by a local general practitioner who works under contract with the hospital and has admitting rights to the local hospital,” explained Dr Zoran.

“It is quite a different model from big city hospitals. We need to develop different sorts of mechanisms to support local efforts. The alternative is that patients have to travel very large distances. Not only is it costly, it is also very inconvenient for patients,” he added.

Some local health districts in the state are as large as some European countries, resulting in a day’s long travel for some patients to reach a hospital whether for an emergency or specialist visit. The inconvenience has a huge impact not only on the patient, but also the family who accompanies them.

Ideally, a rural hospital should be able to support patients residing in its LHD. However, the sheer distance from the city and its relative smaller size means that not as much funding is received. Dr Zoran noted that a disproportionately larger investment was needed to bring rural hospitals to the same level as larger hospitals in the city.

“It is a big disruption for these rural communities. That’s why we started thinking, if we want to have really good telehealth capabilities, or to be able to do video consultations so that the patient does not need to travel, or to have local clinical teams be supported by specialists from a larger hospital using a shared electronic medical health record, we need to have the infrastructure which was up to the task.”

“It was really important for us to ensure that we don’t have parts of our health system that are not able to technologically follow along with the developments in the rest of the state. We decided that we wanted to work as a system.”

Telehealth Projects for Large Geographies

Introducing the Rural eHealth Program. The Program brings together a suite of ICT infrastructure, clinical and corporate eHealth solutions to the six LHDs. Partnership and collaborations are formed, a governance model for all six LHDs are formed, and funding is consolidated. A project worth AUD 48 million, there are plans to increase spending by AUD 43 million in the next four years.

Using mobile technology solutions for remote facilities, clinicians can collaborate across the state. For now, a governance which leverages on partnership is unique in Australia. Based on mutually agreed priorities and principles, oversight and leadership are provided to deliver and adopt eHealth solutions.

A major milestone accomplished is the use of the Electronic Medical Record (EMR). 109 hospitals and 73 sites have ditched paper-paper processes to adopt EMR. At the click of a button, clinicians can now view patient information from across the state, which until recently relied on couriering paper-based patient records.

As an extension of this service, Dr Zoran shared that eHealth NSW has partnered with an organisation to implement point of care laboratory testing in rural places. Local clinicians can do basic tests on portable devices and feed it into the EMR. This allows the central and local team to have a teleconference on how the patient is doing.

What underpins this seamlessness is the Health Wide Area Network (HWAN), a high-speed secure broadband network connecting all NSW public hospitals.

“We’ve connected 140 odd facilities across the state to that network. That gives each rural facility high quality, reliable broadband connectivity to our central data centre. For all our EMR systems to now live in the data centre is crucially important,” said Dr Zoran.

The alternative of running the system out of the central government centre was undesirable. Accessing the system remotely, while hoping for the server’s good performance and reliability was unrealistic. Dr Zoran says since the infrastructure was put in place, it has been transformational.

Some projects which have transpired include the HealtheNet Clinical Portal and the Rural eMeds Project.

HealtheNet links hospital inpatient data and community care patient data through a web-based portal accessed through a patient’s EMR. Based on open standards for interoperability, it sends information to the Commonwealth’s My Health Record system, supporting more coordinated care across hospital, general practitioners and community settings. This provides clinicians with a summary view of a patient’s available health information, without the need to chase and manage paper-based records over large distances.

Additional functionalities such as the Discharge Dispense Record enables rural hospitals to share records of dispensed medications with HealtheNet and My Health Record, enhancing the continuity of patient care across rural and remote areas by increasing content available to NSW Health clinicians.

The Rural eMeds Project delivers medication management solutions to 112 facilities (the largest of its scale in NSW). The Project further improves the safe prescribing and administration of medicines, and a key benefit is a single design resulting in standardisation across this large geographical area. The first go-lives commenced in September 2018 and are on track for completion by the end of 2019.

For now, the team is now looking to increase HWAN’s performance and reliance. They are working with telecommunication providers to have more redundant links and increase coverage in areas where redundant links are not possible. Although physical networking is the solution here, they are exploring the use of mobile network alternatives.

Reliable wireless networks are becoming increasingly important as clinicians become more mobile. Moreover, the wireless networks support the use of other supporting mobile technologies. For example, in several rural health facilities a telehealth trolley which houses a camera and a fully functional clinical work station is used. The technology allows nurses to facilitate a remote consultation with base hospitals in the cities.

“Our health service is able to provide really good service no matter where you live – that’s what it’s about,” said the CIO.

Plans for the Future

At present, the organisation is working on a telemedicine trial called Telestroke in two districts and are looking to scale it across the state.

Telestroke allows a neurologist to provide remote treatment for patients with a suspected stroke. Designed to reduce the time between diagnosis and treatment, the program connects a rural hospital to a neurologist in the nearest tertiary referral centre.

Despite the distance, relevant clinical information and diagnostic images are transmitted efficaciously. Neurologists remotely determine if the patient should begin thrombolytic treatment, or other treatments should be explored, and if a transferral to the tertiary clinic is necessary.

The transfer process becomes seamless. Doctors have a good estimate of when the patient will arrive and can hit the ground running since they have the necessary information beforehand. Hence, as soon as the patient arrives, patients are wheeled to an operating theatre or a suitable treatment facility.

“We are seeing really good outcomes. Because the sooner you treat patients, the better the outcome. Time is absolutely of essence,” shared Dr Zoran. “With this kind of technology, we have no doubt that it can save lives.”

Community health nursing service is another big project they are working on. In the rural areas, community health nurses who conduct home visits require mobile technology to conduct their regular checks.

“This is where we have challenges still,” admits Dr Zoran. “Because not all parts of our state have good mobile coverage. It is getting better over time, but there are still blind spots around the state. A lot of time, our community nurses cannot establish the connection.”

For example, they might want to record a video of the patient but fail to establish a mobile connection given the blind spots. Hence, working with telcos becomes important.

Hence, there is good opportunity for the private sector partnerships. Many partnerships have already been formed in NSW, said Dr Zoran. One area they are looking at is bringing telemedicine into people’s homes.

“If you extrapolate what you are doing between the larger hospitals and the smaller hospitals, similarly, you can go into people’s homes and enable a remote monitoring of patients with chronic illness, so they don’t have to come to the hospital all the time,” shared Dr Zoran.

Ending off with a word of encouragement, Dr Zoran offers, “It is really important to prioritise rural health highly. Develop a good digital plan on how you want to uplift the rural sector. It is also really important to have the local health organisations driving [the initiative].”

“One of the key success factors in our Rural eHealth Program was that the six local health districts which are predominantly rural, are in the driver’s seat. The Chief Executives of those local health districts formed a local eHealth steering committee. They meet every month, work together and prioritise and make decisions together on how they can accelerate. They’ve developed a very good collaborative partnership. That’s been a very key success factor for us. So I recommend partnership collaboration and good governance – that’s the keys.”