TeleHealth - A Revolution in Healthcare?

TeleHealth - A Revolution in Healthcare?

Video consults for distant patients offer many advantages for patients who live long distances from their specialists. This article is written by Nick Brook and Rajiv Singal, and covers many of the issues for this exciting development in healthcare.

What is Video Telehealth?

There is nothing clever about Telehealth, and it’s remarkable that uptake has been so slow. The technology, as voice-over-internet protocol, has been available for a long time - Skype was released 11 years ago. Telehealth simply uses similar or identical technology to link doctors and other health professionals to patients. Travel for remote patients and associated costs are reduced, and in urgent settings, Telehealth can provide rapid access to expert medical opinion.

What are the advantages in Big Countries – Australia and Canada?

Australia is a big place; the sixth largest country after Russia, Canada, China, the USA, and Brazil. Its land size is 7,692,024 km2 with a small population (24.5m). Eleven percent of the population are classified as living in remote/country/rural areas. Canada shares the same challenges as Australia with a similar population spread out over an even greater area.

Australian map showing population density.

There is a marked disparity in health provision between urban and remote areas of Australia, which is extensively discussed elsewhere.

This disparity relates primarily to the practicalities and economics of provision of comprehensive health care in remote areas, and is by no means unique to Australia. In Canada 80% of the population lives within 150km of the US border. With borders that extend past the Arctic circle, the needs of small isolated communities become obvious. Travelling great distances can also be hindered by unpredictable, harsh weather during the winter months.

South Australia is a stand out example of how and why Telehealth can help distant patients. SA has a population of only 1.67m. The Australian Bureau of Statistics give the following figures for population distribution:

South AustraliaMajor CitiesInner regionalOuter regionalRemoteVery remote

SA has traditionally had a close relationship with the Northern Territory in terms of health care provision, and many patients travel to Adelaide from NT for secondary and tertiary care. You can see that travel distances involved for some patients are huge. Much of the care provided must, by its nature, be delivered at metropolitan centres, but much work up and follow up could be performed by Telehealth, reducing costs (economic and social) for patients and government.

As an example, a typical series of encounters for a prostate cancer patient, from GP referral to surgery, is as follows:

  • Initial consult
  • Biopsy appointment
  • Biopsy results
  • CT/MRI/Bone scan (often cant be arranged at the same visit)
  • Appointment for Results
  • Second clinic for decision
  • Pre-anaesthetic clinic
  • Day of surgery

Those highlighted in orange could possibly be replaced with Telehealth appointments. When we consider that some patients make a 2000km round trip for a hospital appointment, the potential advantages become crystal clear.

As well as distant patients, there are potential advantages for Residential Aged Care Facility (RACF) residents, and Medicare Australia has made special allowances for Telehealth to such patients.

It similarly follows that after surgery and the initial recovery phase that many traditional post operative visits could be conducted electronically, particularly when a stable situation is apparent and monitoring of blood work is the main task. Another good fit for urology would be stone follow up for patients on surveillance programs for renal calculi.

Are there any disadvantages to Telehealth?

Inherent in electronic communication is the inability to make physical contact with patients. Nothing can replace an in-person consultation for building the patient-doctor relationship and establishing trust. A handshake is the foundation of consultation, and the ability to examine is lacking. If a patient-end doctor is present, this can be circumvented to some extent, but the quality of interaction is less. Nevertheless it is clear that patients are generally grateful for email access with their treating physicians. A robust Telehealth service would potentially improve upon that.

Co-ordination of appointments can be challenging, as there should be a health-care provider at the patient end. Patients may still need to travel large distances to get to a health care provider with Telehealth facilities.

Electronic communications can break down, although this is rare. More important are potential security issues, which are discussed below.

Why has it taken so long to get this going?

This is difficult to answer. Perhaps established patterns of behaviour are hard to break; as medics, we have become wedded to the in-person consultation. Clearly, advantages and disadvantages of both in-person and Telehealth consults need to be weighed carefully for individual patients.

Set-up costs are minimal, and most specialist and GP practices will have easy access to the readily available technology.

Although government has been leading the Telehealth drive, patient demand is increasingly a factor in health care policy, but rural/country/distant patients may be the least vocal in terms of health care requirements, despite often having the greatest need.

Financial Incentives/reimbursements for Doctors

Various financial incentives are in place from Medicare Australia, through the Medicare Benefits Schedule, with the aim of driving Telehealth uptake. These are categorised as follows:

  • Telehealth On-Board Incentive
  • Telehealth Service Incentives
  • Telehealth Bulk Billing Incentives
  • RACF On-Board Incentive
  • RACF Hosting Service Incentives

These taper over time, and more information can be found here.

Interestingly, rebates for Telehealth are actually higher than for in-person consultations, and this is said (by Medicare) to reflect the infrastructure costs involved.

Systems in use

There is a range of complexity in Telehealth technology. At the top end, very fast connections (where available) combined with fully integrated complex software and hardware allow monitoring of medical information from skin, eyes, ears, pharynx, heart, lungs and other parts of body. Advanced telemedicine can also manage ECG, spirometry, dermatoscopy, pharyngoscopy and endoscopy sessions.

Less complex and costly are installed systems, which essentially build on business teleconferencing platforms. Digital quality is high, and this standard is needed if there is need for diagnosis beyond history taking. These systems still require substantial investment and on-going cost.

The easiest to install, run and pay for are widely utilised software programs such as Skype and Facetime. Most computerised practices will be able to set these up easily, and most health care providers are conversant in their use, so no additional training is required. Quality can be low, and these systems are only really suitable for communication based on discussion and history taking. For example, clinical signs cannot be reliably demonstrated. However, on the principle of ‘the greatest good for the greatest number’, this method of Telehealth probably will have the greatest uptake.

Security issues

Just as in a standard face-to-face consultation, privacy (and digital security) must be absolutely respected. Medical records made at the time of video consultation are recorded and stored in exactly the same way as a standard consultation.

The more costly systems have security built into their frameworks. Systems like Skype and FaceTtime have raised some concern.

The Royal Australian College of General Practitioners has produced an advice document on using Skype, which can be viewed here.

Briefly, that document outlines the concern that the routing path used by Skype often involves data transfer outside of Australia, through countries that may not have the same privacy laws as Australia. For this reason, the RACGP advises that medical content, such as still images or desktop screen shots should not be exchanged during a video consultation using Skype. The RACGP also highlights that configuration is required to ensure that the Skype default of retaining history files, which record all episodes of communication, are set correctly as these files are potentially accessible with spyware. The RACGP do not have a FaceTtime policy.

Both Skype and FaceTime employ Secure Real Time Protocol (SRTP) using AES (Advanced Encryption Standard) 256-bit encryption (also used by the US Government to protect sensitive information).

Likewise, Wi-Fi and wired systems at a health care practice must be encrypted as a further layer of security. As both of these encryptions work separately, it would be very difficult indeed for these systems to intercepted by a third party.

In summary, it is highly unlikely (although theoretically possible) that a Telehealth consultation could be breached, but the risk is probably no greater than the risk of standard computerised medical records being breached by a ‘professional’ and determined hacker. It is the health care provider’s responsibility to ensure the privacy and security of the consultation, that the technical system is reliable, secure and fit for clinical purpose, and that risk management protocols are in place.

The foreseeable future

Increased utilisation of Telehealth may be one of the strategies to help address the huge and unprecedented growth in Healthcare need, which is forecast to continue.

The tables below are taken from the MBS Telehealth Statistics.

The first demonstrates a steep uptake of Telehealth since 2011, but perhaps a developing plateau, which would be typical of saturation of the technology savvy medics. Hopefully, over time the service will expand further, but this will rely on patient acceptance and satisfactory feedback.

Number of Providers by Selected Subspecialty - claims processed as at 31 March 2014

The second table shows claims processed by specialty, and it is encouraging to see urology near the top. Further expansion in our specialty will be partly patient driven, but also requires support from specialty bodies.

Services by Year and Quarter – claims processed as at 31 March 2014

The Australian Telehealth Society has produced a position paper on a National Telehealth Strategy to 2018 that is worth reading.


Essentially, the aim of Telehealth is to improve access to health care for patients who are disadvantaged by their location – its all about taking health care delivery in the direction where we can better scale the doctor to patient time.

Nick Brook is an Associate Professor in Surgery at the University of Adelaide, and Consultant Urologist and Director of Urological Cancer at the Royal Adelaide Hospital in South Australia. You can follow Nick @nickbrookMD on Twitter

Rajiv Singal leads the Surgical Robotics Program (jointly run by TEGH and Sunnybrook Health Sciences Centre) and is an Assistant Professor in the Department of Surgery at the University of Toronto. He supervises the Clinical Endourology Fellowship program at TEGH under the umbrella of the University of Toronto.

You can follow him @DrRKSingal on Twitter

Categories: Video, Updates


Nick Brook Urology Moving to New Location

Nick Brook Urology Moving to New Location

The North Adelaide practice has grown rapidly, and we are moving the rooms to a new location. We will be moving on the 16th December, and will be sending details through the post to all our patients.

Where are we moving to?

The new address for the the practice is Calvary North Adelaide Hospital (Ground Floor), 89 Strangways Terrace, North Adelaide SA 5006. The new telephone number is 08 8267 1424

The email address and website will stay the same; email: This email address is being protected from spambots. You need JavaScript enabled to view it., website www.nickbrookurology.com

Why are we moving?

The practice has grown significantly and the new location at Calvary North Adelaide Hospital has more space to allow for staff expansion, but importantly will offer many benefits for patients:

  • Located in a major private hospital
  • Easy ground floor access for patients, with 2 hour parking
  • Direct access for patients to radiology and pathology - located on the same corridor
  • On-site access for patients to Continence Nurse expertise
  • Immediate booking of procedures from clinic
  • In-patients have access to our office facilities and support

When are we moving?

16th December 2014. If you have an appointment prior to this date, then please come to the old 175 Ward Street address. After the 16th December, all consulting will be at Calvary North Adelaide Hospital. We are on the ground floor. Just ask at reception, and they will point you to the new rooms.

What if I need further information?

We are writing to all our patients and their GPs to let them know about the move, with all the details of the new location. If you have any questions, Jane or Heather will be pleased to help. Before 16th December, call them on 8267 2200, after that date, call them on 82671424. We apologise for any inconvenience, and we are confident that you will find the new location is able to meet your expectations as a customer of the practice.

Categories: Updates


Enzalutamide available on the PBS

Enzalutamide available on the PBS

From 1 December 2014, a new drug for advanced prostate cancer will be available and listed on the PBS. Enzalutamide is an oral drug used for advanced prostate cancer (metastatic castration resistant prostate cancer). It works by inhibiting binding of androgens (such as testosterone) to the androgen receptor (AR), as well as inhibiting the AR from entering the cell nucleus and from binding to DNA. It has had encouraging results in clinical trials.

What are the PBS criteria for enzalutamide?

The treatment cannot be used in combination with chemotherapy (docetaxel in the common chemotherapy agent used in advanced prostate cancer)


The patient must have failed treatment with docetaxel due to resistance (this generally means progression of disease or non-response to docetaxel) or intolerance


The patient must be unsuitable for docetaxel treatment on the basis of predicted intolerance to docetaxel


Patient must have a World Health Organisation Performance Status of 2 or less (this means good performance)


The patient must not receive PBS-subsidised treatment with this drug if progressive disease develops while on this drug


The patient must not have received prior treatment with abiraterone


Patient must have developed intolerance to abiraterone of a severity necessitating permanent withdrawal of abiraterone.

Categories: Updates, Prostate Cancer


Abiraterone PBS listing changed from 1st December 2014

Abiraterone PBS listing changed from 1st December 2014

From December 2014 , the PBS criteria for abiraterone acetate changed, meaning that patients deemed unsuitable for chemotherapy with doxetaxel can be prescribed PBS-subsidised abiraterone.

What is abiraterone?

Abiraterone is an oral drug for metastatic prostate cancer that is castration resistant (meaning the cancer that is no longer sensitive to other forms of testosterone suppression). It works by inhibiting an enzyme involved in the production of androgens (testosterone is one of the body’s androgens).

What are the new amended PBS criteria?

Treatment must be in combination with a steroid (prednisolone)

Treatment can’t be given in combination with chemotherapy

Patients must have failed treatment with docetaxel because of resistance or intolerance, or be considered unsuitable for docetaxel chemotherapy because of proven or predicted intolerance to the chemotherapy.

Patients must have a good performance status (WHO status of 2 or less)

If progressive disease develops whilst on abiraterone, PBS-subsidised treatment with abiraterone cannot continue.

Patients cannot have previously received treatment with enzalutamide, or they must have developed intolerance to enzalutamide, which was bad enough to require that enzalutamide was stopped.

Categories: Updates, Prostate Cancer


Should I have a PSA test?

Should I have a PSA test?

This short article may help you with the decision about having a PSA test (also known as PSA screening) to look for prostate cancer

Australia has one of the highest rates of prostate cancer in the developed world. The PSA test is the first investigation that can be done to look for prostate cancer. It is not a perfect test, and there are problems associated with the test, which is why you should be as well informad as possible about PSA.

Information for Patients Considering Prostate Cancer Screening


  • Prostate cancer is common. Most men will develop prostate cancer if they live long enough. Despite this, only about 3% of all men will die of prostate cancer.

  • This indicates that most prostate cancers do not cause trouble in a man’s lifetime (‘low-risk’ or ‘indolent’ cancers). However, there are some more aggressive cancers that can cause trouble, and these benefit from detection and treatment.

  • Screening studies do show that the number of prostate cancer deaths can be reduced by screening with PSA. However, quite a large number of men need to be diagnosed by screening and treated to prevent one prostate cancer death.

  • One study (the Goteborg study) showed that 12 men need to be diagnosed to prevent one prostate cancer death. That means that 11 men were unnecessarily diagnosed. Another larger study demonstrated that (ERSPC) that 781 men need to be screened and 27 men need to be diagnosed to prevent one prostate cancer death. Thus 26 men are unnecessarily diagnosed.

  • Screening will detect many of these indolent cancers, and if they are detected, they may go on to be treated, perhaps unnecessarily.

  • Treatment is associated with long term complications in men, such as incontinence, erectile dysfunction (impotence) and bowel problems. Therefore, some men (indolent cancers that are treated) may have unnecessary treatment and suffer side effects.

The aim of screening

  • The aim of screening should be to identify aggressive or high-risk prostate cancers early, before they have spread beyond the prostate.

  • Some men are at higher risk of aggressive prostate cancer than others. These are men with a family history of prostate cancer, or with a strong family history of breast or ovarian cancer in females of the family, men of African-American decent, and men who have been exposed to some environmental agents (fire-fighters possibly, and veterans exposed to Agent Orange).

  • Most prostate cancers found by screening are low risk and do not need to be treated, and can just be closely followed by active surveillance (click for link to AS).

  • If you choose to be screened, there is a reasonable chance you will be diagnosed with low-risk prostate cancer, and may be in a position where you have to consider treatment that may be unnecessary.

Your decision to be screened – what sort of person are you?

  • If you have risk factors for prostate cancer (see above), your risk of prostate cancer may be higher than the general population, and this may impact your decision to be screened.

  • If you are the sort of person who would be uncomfortable not being treated if low risk prostate cancer was discovered, screening may not be the right decision for you.

  • If you are the sort of person who would accept treatment for aggressive prostate cancer, but would be happy to observe (active surveillance) things if you just had low risk prostate cancer, then you may be a good candidate for screening.

Categories: Updates, Prostate Cancer


Video TeleHealth for Distant Patients

Video TeleHealth for Distant Patients

Video consultation is now available at Nick Brook Urology, to reduce the need for long distance travel for rural and country patients in South Australia. This service offers a real time consultation over a video link from your GP’s practice, so you can talk directly with a Urologist.

How does it work?

If your GP has made a new referral and has requested a video consult (‘video telehealth’), this will be sent to Nick Brook, who will review the referral and see if it is suitable for a video consultation. If so, the staff at Nick Brook Urology will contact you and your GP and a time will be arranged for you to attend your GP practice for the video consultation. One of the staff from your GP practice will be with you during the consultation to help you. You do not need to do anything special – all of the organisation will be taken care of, and all you need to do is talk with Mr Brook, as per a normal consult.

Any investigations, such as blood tests or X-rays, can be arranged easily, and will be faxed to the GP practice so you can have them done near to your home. Follow up appointments can be arranged by video as well.

Are all consults suitable for video telehealth?

You need to live in an area that is deemed appropriate for telehealth by the Government. In South Australia, this means you need to live outside of the central area coloured in red in the map below:

Map outlining Adelaide metro area

What happens if I need a physical examination by the Specialist?

Because examination cannot be done at the time of video consults, it may be that your consult may not be suitable for telehealth. You may still need to travel so that this examination can be done. Likewise, some specialised investigations may need to be done in person. However, an initial discussion by video can reduce the need for multiple visits, even if you do have to come to Adelaide for a face-to-face consult at some point.

Is the video recorded?

No, there is no video recording made. However, medical notes are made as with a standard face-to-face consultation.

How do I request a video consultation?

Ask your general practitioner if they have the facilities available for a video telehealth consultation. You can also contact Nick Brook Urology to help arrange this.

Can I have a family member or friend in the room for the consultation?

Yes you can. It is helpful if you let your GP know about this prior to the consultation.

Is your privacy respected?

Just as in a standard face-to-face consultation, your privacy is absolutely respected. The only people involved in the consultation are you, Mr Brook, and one of the staff members from your GP practice. Contact will be made before and after the consultation by practice staff, to arrange investigations and follow-up. Your medical records are recorded and stored in exactly the same way as if you had a standard consultation, on our secure electronic record system.

Generally, a program called Facetime is used, and this is an encrypted system. Facetime is streamed via Secure Real Time Protocol (SRTP) using AES-256 encryption. Likewise, WiFi and wired systems at the practice are encrypted. Both of these encryptions work separately so it would be very difficult indeed for these systems to intercepted by a third party.

A video telehealth consultation has been suggested, but I do not want one. What do I do?

You are absolutely free to decline a video consultation and have a face-to-face consultation instead. Please let your GP and Specialist know about this, and this will be arranged for you.

Categories: Updates


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  • Nick Brook Urology
    Calvary North Adelaide Hospital
    89 Strangways Tce,
    North Adelaide,
    Adelaide SA 5006
  • 08 8267 1424
  • 08 8267 1370