An accidental career in telehealth

Chris Ryan
Nov 22, 2018 · 13 min read

I wish I could explain more easily that Attend Anywhere is a systemic framework and approach for enabling mainstream video call access to existing health services, as opposed to a technology (as is commonly misconstrued) (or even more incorrectly, a video technology).

Yes, we develop management software that sits between peoples’ video technologies and hospital systems, and yes, we provide online resources and materials to support adoption, but from our perspective, these are just tools that have evolved to help people put the framework into practice.

Having been at the bleeding edge of using video technology in health care for almost 25 years now, I recently shared a few lessons; both as a video consulting program manager myself, and in the service of working with others towards a shared vision.

As part of that, I was encouraged to share the experiences that brought into being the decentralised, patient-centric enablement framework that is now benefiting health systems in in both Australia and the UK. (I’ll try and be brief!)

Bitten by the bug

In the mid-nineties, I worked for a PictureTel partner in Melbourne. PictureTel was one of the first companies to offer low-bandwidth video conferencing using digital connections called ISDN.

I met a psychiatrist from Bendigo who thought this new technology could help him deliver child and adolescent mental health services up on the Mallee Track.

My mother was a Director of Nursing (DON) in the regional town in which I grew up, so health was in my blood. I said, ‘Hell yeah’. (And, being fresh from the UK, “Where’s the Mallee Track?”)

Unknowingly, we went on to install some of first video conferencing systems in the world that were used specifically for health.

I became passionate about the potential good that could be achieved and, without realising how long it would take, began an accidental career in telehealth.

After installing around 100 systems in rural areas on just a whiff of the potential value (funded by mental health reforms at the time), I had to concede it didn’t work very well. Once the press and the politicians had left, the systems just sat there.

There were many reasons for this, but the main ones were a lack of health care providers at the other end, and the need for overarching coordination.

In 1998 I stopped my involvement with the technology side and founded Global Telehealth (now called Attend Anywhere) with an aim to reduce the barriers to its adoption.

Early efforts to turn the vision to reality

One initiative, in partnership with the Victorian Hospitals Association, was Telehealth Victoria — The first one, not the vibrant, Department of Health and Human Services-sponsored Community of Practice we have now. (Thanks to the efforts of Alice King and Susan Jury, Lindy Johnson and others.)

We delivered training and awareness programs, and successfully lobbied Telstra for reduced ISDN call charges for telehealth.

We raised funds to install a video conferencing system at the Emergency Department of the Royal Children’s Hospital in Melbourne, one of the first to be installed in a metropolitan centre.

In an attempt at coordination, we also assembled what would have been one of the first telehealth directories.

In 2000, with the support of the then-CEO, Dr Michael Walsh (who was chair of the first national telehealth initiative as I recall), I began work with the Alfred Hospital in Melbourne and ended up being based in and around there for the next 20 years.

We obtained a large Department of Health and Human Services (DHHS) grant to establish video call access to Alfred-based clinicians, working with hospitals in Gippsland (who had already had the video conferencing systems).

Long story short — we failed. (Though we did learn a lot!) Lessons included:

  • Do not confuse initial excitement and enthusiasm with ongoing sustainability
  • It is difficult to get an orthopaedic surgeon to change rooms to where the video conferencing system is!

We did succeed on two fronts:

  • Service exchange between Alfred Health’s own campuses (because the benefits and the financial savings could be tracked by the Alfred)
  • Enabling video call access to the Physician Education Program provided at the Alfred for basic trainees that were on rotation in the bush

The Physician Education Program (PEP)

The PEP, which commenced in 2002, was led by Professor John Wilson (now President of the Royal Australasian College of Physicians — RACP), who has been a constant source of input, ideas and encouragement over the journey.

The PEP, again supported financially by the DHHS, involved 155 hours of lectures that started with five participating sites, and grew to 800 basic trainees attending every Thursday night across 90 hospital video-conferencing locations in Australia and New Zealand. (And we only owned one video conferencing system!)

In hindsight, this was a mammoth achievement, that forged many aspects of the enablement framework in use today.

We realised that what we were doing was just replacing the travel component involved with service delivery, a video conference system just replaced the car or a train — everything surrounding that should remain the same.

The framework was inherently inbound from early on (initially so the person receiving the service, dialled the call and paid the ISDN call cost), and decentralised. Both of these were key to program sustainability and scale.

The first version of our management platform

The PEP was also the beginnings of our video consulting management platform, an invention borne of necessity.

We started with trainees at 5 locations, which needed to grow quickly to 30, then 65, then 85. In order to handle the volumes of participation cost effectively, we needed to automate event administration and coordination. The software was web-based from the beginning. It allowed hospitals to register their video conference room as a Local Venue (and receive dial-in instructions), and physicians to subsequently register to attend at one of the Local Venues (and receive session handouts and so on).

The management platform also coordinated activity between dozens of support staff in various hospitals (dubbed local venue coordinators in our early model). The up-to-seven bridging organisations (conferencing service providers) tied it all together technically. The complexity was mind-boggling when I think about it.

I am proud to say that the PEP was the first of dozens of programs that were developed after that, some of which are now entering their 18th year. (Albeit, using a very old version of the management platform.)

Direct-to-patient video consultations — early efforts

We started designing in-bound patient access to health services around 2010, again with John Wilson and the Cystic Fibrosis team at The Alfred Hospital, as well as with Monash University, with funding again from DHHS.

We started by sending links to virtual meeting rooms and then, as we got more sophisticated, links to appointment times.

We didn’t know it at the time (we thought we were going great guns!) but in hindsight, shoehorning conferencing workflows into clinical service delivery settings was difficult.

Clinicians and patients from the Alfred and Melbourne Health using Vidyo

We were on version 2 of the management platform by that stage, which took advantage of technology innovation from a new video conferencing company called Vidyo.

Vidyo did two things differently:

  • they offered API’s, so our management software could automatically send links (instead of requiring dial-in instructions to be entered manually)
  • and they radically improved the quality of the video transmission over imperfect networks such as the Internet. The ability to use the Internet for the first time (without needing specially quality-of-service connections) saved the ISDN call costs.

Having seen a demonstration, I flew to the US to be further impressed. We became their first customer outside of North America, I believe.

The invention of the button

Around 2011 we launched the first Attend Video Appointment button, that was the forebear of the hundreds of buttons on health care provider websites today.

I thought it was a massive leap forward, but it didn’t set the world alight, much to my bewilderment — too early.

A new benchmark for success

Our focus on mainstream patient access accelerated from 2012, onward through our work with Healthdirect Australia, and Prof. Anton Donker, Healthdirect’s CIO at the time.

Healthdirect Australia is a Government-owned organisation with telehealth in their DNA that provided, ‘consumer access to health information and advice via innovative technologies’. In its early years, that was the telephone, but thanks to the great work of lots of people, this now includes a range of digital channels.

Our task was to enable video call access to Healthdirect’s own call-centre-based health services. This is where the definition of ‘success’ completely changed.

Suddenly, the benchmark for cost, ease-of-use, quality, and access became the telephone as opposed to the tyranny of travel. (Compared to which, it is easy to look good and cost effective.)

We needed to support urgent, unplanned video calls from consumers anywhere in Australia. People could be attended to by any one of a number of clinicians, as well as be transferred between services if necessary. There was no opportunity to set anything up beforehand or install anything.

All this was within a government health care context, where the standards and expectations for privacy, security, and data protection were extremely high.

Our own platform was purely internal at that stage (used for our own projects) and not even considered an option, due to conflict of interest perceptions.

We explored all sorts of workflow technologies from all over the world that, with a couple of exceptions, did not deliver due to provider-centric designs as opposed to patient-centric ones.

The workflow management layer aside, the fact was: The video technology didn’t yet exist that could match our requirements.

All our tests and proof-of-concepts showed that however simple and automated we made it, it just wasn’t feasible to ask callers to install a video software client prior to making a call.

Flash video technology, that was already installed on most PC’s, was the only other option, but it was shown to have a lot of drawbacks, not just from a security standpoint as the world now knows (and as Steve Jobs resolutely pointed out!) but in terms of quality and reliability in variable Internet conditions.

Web Real Time Communications (WebRTC)

The Alfred Cystic Fibrosis service was one of the first to benefit from WebRTC — this is a very early version of the call screen.

One day, an AA software engineer called Raj Jawanda showed me a very rudimentary example of WebRTC working between browsers and on a mobile. I almost cried.

This video technology was open-source and still at the bleeding edge, but it was compelling, and we were out of options. It was the best quality, most resilient video technology we had ever seen, and it was free. The fact it travelled between browsers and not through a central data centre also offered many cost and quality advantages, especially for those in regional areas.

Sincere kudos to the CIO and CEO at Healthdirect Australia at the time for allowing us to pursue such an unproven bet.

We established a partnership with an R&D organisation called NICTA (now Data61) that was also Government funded. NICTA were doing some cool open-source work with WebRTC at a deep technical level that we were able to leverage at the time — and still do. Warren Mcdonald from our end, and Silvia Pfeiffer from NICTA were key drivers, working with an international community of early adopters. (sidebar: inspired by the work of Attend Anywhere and the market opportunities, Sylvia went on to spin a company out of the Data61 work called www.coviu.com.au focused on video call access to health services).

Healthdirect Video Call: mainstream video access to existing health services

Using WebRTC turned out to be a good call, and our work with Healthdirect helped pave the way for many solution developers in the health space. This is as it should be, given taxpayer dollars funded it, and it makes me proud of our work and all the people involved. See 2013 Pulse+IT article.

In order to explore platform options, Healthdirect independently ran an expression of interest (EOI) and a request for proposal (RFP) process, to which Attend Anywhere was not allowed to respond. The Interaction360 solution was in the box seat, but tightly integrated with Flash video technology and not able to switch to WebRTC without a major re-write.

The EOI established that there were no viable options on the market at the time. Our own internal management platform was already web-based and designed to use any video technology engine, meaning it was viable to switch to the open source WebRTC. It was this that was subsequently approved for use by Healthdirect and its stakeholders.

The combination of a mature management platform (which was where the real value lay) and cutting-edge video technology proved powerful and produced one of the first, entirely web-based, video consulting platforms in the world.

In October 2014, after the launch of video call access to the first of Healthdirect’s own services www.pregnancybirthbaby.org.au, the federal Government funded Healthdirect Australia to establish national exemplars of how mainstream video call access for patients could be achieved in a variety of common health care settings.

We collaborated with several state-based organisations to achieve this. In doing so, we gained valuable insights that would underpin our approach to scaling up the Healthdirect Video Call program (as it became known) when it was expanded the following year.

Read more at https://about.healthdirect.gov.au/video-call

NHS Scotland

In 2010 at a Health Informatics Society of Australia (HISA) telehealth conference in Cairns, I met Jim Ferguson, who was the clinical lead for the renowned Scottish Centre for Telehealth and Telecare (SCTT) and a paediatric emergency medicine consultant.

In 2015 when I was travelling with my family in Europe, I took the opportunity of spending a week with the SCTT during their Digital Health week, which was fabulous. I shared our own progress and the work we were doing with Healthdirect and it aligned well with the direction the Scots wanted to head. They also saw the opportunity, as did Healthdirect, to share learning around direct-to-patient video access.

A few months later, when NHS Scotland ran a public tender for the provision of a patient-centric telehealth capability, Attend Anywhere responded. We were successful, and the Cabinet Secretary for Health launched NHS.AttendAnywhere in December 2016

This was the first time we had bundled our platform and services in to a standalone hosted offering, which was an interesting journey, as we did not (and still don’t) view ourselves as a software company. The software is a means to an end.

Thanks to a range of factors the Attend Anywhere program, which now incorporates initiatives such as NHS Near Me and the new GP Near Me is being enthusiastically adopted.

https://sctt.org.uk/attendanywhere

First foray outside of public health services

In 2017 Attend Anywhere received an innovation grant from the Department of Premier and Cabinet to explore video call access to the providers Family Violence related services.

This involved establishing a hosted version of the management platform for use outside of the public health system.

In 2018 individual private practitioners were given access to the management platform for the first time, although this has not been widely publicised.

Our decentralised, patient-centric enablement framework

The fact we grew up in Victoria had a lot to do with the how the framework evolved.

Being a relatively small state, telehealth in Victoria was not a political priority, so everything had to be financially sustainable. Victoria had a decentralised healthcare system, there was no shared technical networks or services, no telehealth department and no shared finance systems (making it easier to reconcile the savings in one area of the system to the costs in another) so we had to facilitate or work around all of that.

At the core of the framework is collaboration and co-design throughout, particularly with patients, clinicians and clinic staff, and also with other program managers.

You can read more about the framework principles in Enabling mainstream video call access to health services (and why video conferencing can’t cut it)

In Summary

It’s taken a long time for the technology to catch up with the vision, but I am proud to say that the core values we set out with, and the principles of the decentralised, patient-centric model are more relevant today than ever.

I am also proud that so much of our model and language has been emulated in so many great products and solutions out there that have joined in. A key objective of the Healthdirect Video Call program (potentially lost in recent times) was to build develop a market.

The journey and achievements would not have been possible without the expertise, commitment and shared passion of long-term colleagues and friends such as Mark Rodrigues, Warren McDonald, Raj Jawanda and many many others.

The same goes for all the patients, clinicians, other health care professionals and leaders that have supported, encouraged, led and mentored us toward this shared vision. You meet a lot of people whose default position seems to be ‘no’ or to protect the status quo. These are people who always try to say ‘yes’

In 2010 the Commonwealth Government had set aside $50m to enable video call access to a just one of Healthdirect Australia’s services, without any idea of how this could be done.

Our team not only ensured that this was achieved for a fraction of the budget, but in doing so built a capability to support thousands of public health care providers embed secure video call access within their existing service offerings.

We now collaborate directly or indirectly hundreds of health care organisations in the public health sector — most through partnerships with Healthdirect Australia, and the NHS.

The framework and capabilities continue to improve, with collaboration at their core. They are made available on a philosophically not-for-profit (all-you-can-eat in Australia) basis, for the benefit of everyone accessing public health services.

It is satisfying that the vision is beginning to deliver real mainstream value.

Chris Ryan

Written by

Video consulting program manager, now helping other program managers enable business-as-usual video call access. Founder of Attend Anywhere.

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