Tim: [00:00:00] I'm Tim Panton, and this is the distributed future podcast. Unfortunately, normally Vim is here with me, but, due to a technical mess up on my part, the recording of her intro isn't here, so, you get me. So the distributed for future podcast is where we interview people who are doing interesting things in niches potentially, and, but certainly on the edge between tech and society.
And we look at how those things may, influence how we all get on in the future. How future society may, evolve. This episode is, a discussion about telemedicine. On the webpage, you'll find some show notes that, have links to some of the topics discussed for your deeper evaluation.
Sylvia: [00:00:55] I'm Sylvia Pfeiffer. I'm from Sydney, Australia. I run a small startup called K view C. O, V I, U. And, we have, built a telemedicine platform, built on web RTC. originally I was involved at the W3C in some standards work around HTML five video.
but in a, after web RTC came along. we, we started building, a video conferencing platform and then really focus that in on telehealth. and that's what we're doing these days.
Tim: [00:01:27] So, so who are your, I mean, you about telehealth. Who does that serve? Who your, your end users for telehealth?
Are they
Sylvia: [00:01:36] local or. Yeah. So we built a B2B platform, not a, like a, a lot of other companies in that place are actually in that space, are actually directly selling to patients. They hire a bunch of clinicians and, and, try to get, you know, a clinician, patient platform going, a little marketplace.
We, we immediately focused on actually enabling healthcare businesses with telemedicine. So our, our approaches B2B, we are completely white labeled. We, have sold into a whole bunch of companies in Australia, but we've got servers across the planet. and, immediately at the moment, we're really still selling Australia, New Zealand.
although we do have a couple of international customers already.
Tim: [00:02:23] So, so talk me through how a clinician in a health business might use what you're doing. I mean, it is. So this is between maybe an expert in a local practitioner, or how does it fit.
Sylvia: [00:02:37] It's, I'm focusing on direct to patient tele-health.
So it's not between clinicians. It's, it's, it's enabling healthcare businesses to meet with their own patients. we're not standing in between. We're just the software that's enabling these clinicians to, to do it almost like a practice management software. but, we're, we're behind the scenes with our software to enable them to, to offer these services.
So, for example, we've got a lot of speech therapy, speech pathology, speech therapy, businesses, that have, gotten a license of career view, software as a service platform. so they pay per clinician. And then they make available these clinicians to their patients, to hold video consultations.
And that's often in Australia rural patients. It could be patients in schools, in rural areas, it could be patients at home, in rural areas. we, we have a lot of customers in mental health, so lots of psychologists, psychiatrists. And in similar mental health workers. there's a physical therapy that, physiotherapists and occupational therapists and exercise physiologists.
There's also, an increasing number of general practitioners and specialists that are using our platform.
Tim: [00:03:58] So in this case, you'd have like, a patient who is somewhere maybe several hundred miles away from, from the clinician and the clinician would be talking them through exercises or watching them move and, and commenting on, on how they might improve the, the balance or something.
Is that amount, am I getting in the right kind of image that.
Sylvia: [00:04:21] Yeah. Yeah. Basically that's, that's the right kind of image. So most, most therapy starts with, an analysis. So, the, the therapist might, in the first instance, actually asked the patient what's wrong with them? maybe they, they in, in physical therapy that which they would show where it's, where they're in pain.
they would ask them to do certain movements so they could see their range of motion and what's where, where they, you know,
and then after that, after that, they do therapy with them. So for example, they give them all these exercises to do. They watch them do it, they correct them, how they're doing it. And then every week they meet again to see how the progress is going and whether they've improved, et cetera.
You can do that quite well over video with physical therapy. People would, would not necessarily think that would be possible. Cause a lot of physio therapists actually do touch patients. but, there is a new type of physical therapy that that's, gaining more and more interest.
Which is to enable the patient to do these things themselves rather than doing it to them. Like, for example, if you as a physiotherapist, always try to stimulate a certain certain muscle, the muscle becomes sort of lazy and doesn't do it themselves anymore. So the idea is to activate you to, to do it yourself and to support you in doing it the right way so you don't hurt yourself.
and, and so that's, that's, that's kind of really. easy to do over telehealth.
Tim: [00:05:50] So these services that have never been available in those localities before. So is this a new experience for maybe that community?
Sylvia: [00:06:01] Oftentimes, yes. So the, in the history of telehealth, at the last. Well, maybe, maybe until a couple of years ago, telehealth has really been used mostly between large and smaller hospitals, because in the past, it required installation of, of software and hardware that would be a custom placed and custom installed.
almost like, like a boardroom system. And then people would directly connect through those systems. So it would never go into patient's homes. And this is because a lot of people didn't use to have access to the internet. They didn't use to have enough bandwidth. That didn't use to have the right kind of hardware.
You got to remember that the quality of cameras that we have now and mobile phones is outstanding. It is amazing compared to what we had like even 10 years ago, 10, 15 years ago for the kind of camera quality that you're getting now. You had to pay a lot of money. So, that progress is now really leaking into people's homes and allowing people to do, direct to patient.
Telehealth, which wasn't really possible before.
Tim: [00:07:09] I was gonna say, what do you, what? What does this look like? Do people go into a clinic and and work maybe with a practice nurse who's kind of supervising from that end, or do they genuinely just do this from home?
Sylvia: [00:07:24] A lot of times it's from home. It could be anything.
Of course, you could create a rural hub that has a set up and into it from there. But most of our customers are actually seeing their patients at home, at their homes, and that has a lot of advantages. For example, in mental health. the. Every mental health assessment that you do with someone tries at first in the first like 15, 20 minutes to find out about their circumstances, their background, the, the way they live, et cetera, et cetera.
When you do that via video straight into people's homes. You immediately see the background, you see them in their natural habitat searches, and you see exactly what's going on. and you don't have to ask half of these questions because you can see it. It's, and it, it builds a much better.
Trust relationship between the patient and the clinician. Because the, the clinician doesn't have to ask a lot of these awkward questions. they can approach you immediately with the certain, with, with, with, with the more in depth questions with the, you know, the right kind of questions. it's, it's, it's also.
A lot less stigma around seeing your health practitioner, your mental health practitioner, or if you're doing it from home because you just close the door or you're at home, you are feeling comfortable and you have a call with your practitioner. Whereas if you have to make an appointment, you, even in a small town, particularly if there is like one psychologist that.
People go to, it's your seen walking down the street to the psychologist. Now the whole neighborhood knows about it, et cetera. You might want to avoid that. So actually tele health is really good for that kind of,
Tim: [00:09:01] care. Right, right. No, that's, that's fascinating. So, that brings in into the kind of concepts of privacy, is that, do people feel.
Like people associate their phones with sort of Instagram and Facebook. Do they feel that that conversation is sufficiently private and and and privileged or is there a nervousness around that? Ah,
Sylvia: [00:09:25] I bet there is. Because of course, people know that if they are using social media on their phones, et cetera, lots, lots of their data can leak to other people too.
You know, areas that they might not want to get into. and, and this is also one of the reasons why we don't recommend using Skype or FaceTime, you know, any of the, standards. person to person, you know, friend communication mechanisms, because that data might be stored and, and could, could go in, in all sorts of places.
Whereas we as a health care specific provider, we make sure we handle the patient data with utmost. A privacy and security. And with web RTC, that's really easily done because your, your call is, is encrypted end to end and, therefore really hard for anyone to, to listen in on to. we, we further don't store any patient data.
We have patients just come in via a link. They, we don't store any of their names and things like that. So we, we keep. A minimum profile of all the, the, patients that, that, that use our service.
Tim: [00:10:37] So just thinking through how this kind of feels to the patient. Do, do they, do they like have an app which they then enable and choose a camera and make, how does it sort of, how do they work through it and how do they feel, felt, found their way through it.
Sylvia: [00:10:54] Yeah. So we have two, or actually three different ways, for the, healthcare practices to do it. one is simply, with an appointment booking. So patient goes to a website, clicks on a link, makes an appointment booking, and as part of the appointment booking, they get sent back an email with the link in it.
for a particular time and in a booking that they can put into their calendar. And, of course, at the clinician end that goes into the practice management software. So when the clinician comes to that appointment, they know that this is an online one. They click on the link and the patient clicks on the link that they've received to our email and they hold their consultation.
that's one way. Another way is. What we call a virtual clinic. So, it could even be done by a hospital. So a hospital might put a link up on their website saying, visit our. Of teleneurology clinic or whatever it is, just click here. So people click on that link. As they come in, they put a couple of pieces of information about themselves in there.
There is no sign up anywhere ever. they just just, provide some details so that when they're in the waiting queue, the clinicians can identify them. And so when they're in the waiting queue, someone can triage them, can see what they are in, what they're coming for, can find the right doctor for them.
And then the doctor picks them up, holds the consultation, and at the end of the consult, all the information about the patient gets purged.
Tim: [00:12:24] Right? So, so. I'm interested in, in knowing whether these patients ever physically meet the clinicians, or is there like a crossover between the virtual and the physical, or are they like totally, is it a totally virtual interaction.
Sylvia: [00:12:44] a very good question. every clinician kind of works differently. So let's talk about, hospitals that are using our platform. Oftentimes what it is, is a outpatient clinic, which is after an operation. People go back home. in Australia, the huge distances, so they might be home, might be a couple thousand kilometers away.
and, then all they do is seeing their, clinicians in the outpatient virtual outpatient clinic via video online. So they would have seen. Met the clinician in person, might've even been, you know, in, in surgery with them or something. And, and they follow up via video with them.
Now, other clinicians that we have used the platform exclusively for online consultations, particularly in mental health, they would have never seen their patients in person. And they can still build a, a, a trust trusting patient, clinician relationship with them via video.
Tim: [00:13:45] Right, right.
That's fascinating. So like. You're looking at several thousand potential kilometers distance. and is that because their people want to see an expert in the field or or is that just like family relationships? How do you end up with a doctor who's that far away?
Sylvia: [00:14:07] So think of Australia as a little, a large country, very, very thinly inhabited with, how many, maybe eight major centers.
All of the capitals, are, are basically, you know, there's a lot of people in the capitals and in the urban areas, but apart from there, there's not a lot of, population density. so. If you, let's say you live in Western new South Wales, you, you are thousands of kilometers away from a specialist clinic.
Your closest clinic might be, would be your local hospital. and, your local hospital might just be a as big as you know, two or three clinicians at most. and that's like a, a small country hospital. Then there's, there's one that's probably in a, in a more rural center, quite a bit bigger.
and you could go there for your operations, but if you have something very, very special, very specific, you will have to travel all the way to the, to the Capitol, or to, to one of the big centers to, to, to get it done. And then of course, if you've got something very specific. You will want to get, treatment from that person who is the expert, in, in your follow up.
so that's, that's how that happens. the other thing is that of course in the urban areas, you'll get the general practitioners, but you will not get, a high density of, of allied health practitioners, of speech pathologists, of exercise physiologists of dieticians. etc because there just isn't enough.
population density for them to, to have to set up shop there. So, that and the specialists, they're really, really rare in, in rural areas. So even, even if you wanted to see someone there, the closest one might be two or 300 kilometers away. And that is enough to, consider, telehealth.
Tim: [00:16:05] Right. So, so I like a few kind of technical, questions. Now I think around, what kind of bandwidth is the bandwidth you need freely available or there like people have to kind of sign up for a special plan with their ISP in order for this to work?
Sylvia: [00:16:21] Yeah, very good question. So, we. We have different plans in Australia and we have different, different, capabilities available where you live.
So we have, a thing called the national broadband network. It's an activity that's been going on for, I don't know, five, six years, maybe a bit longer. we've been trying to set up a universal. broadband network that any Australian citizen would be connected to, and that would require, of course, connectivity quite possibly over satellite for very rural areas.
but in general, the idea was to put fiber, to, to the, well. To the homes or to the curb or to a rural center, to at least get, get really good backbone connectivity, and then you would have a, a pretty good connectivity through, through that interconnected network. now parts of Australia have received that kind of great upgrades, in parts of Australia haven't.
So you will find areas where the, there won't be any internet other than satellite. and there are parts that have, you know, pretty good internet. for Australia, let's say, you know, 20 megabits or something. in general, we, we have to deal with about, you know, 120. Up to 350 kilobits a second, in, as, as some of the minimum networks that we have to deal with.
Sometimes people have even worse internet. but in general, the internet is getting better. I, I still think we probably have one of the worst internets on the planet. So a running a reliable web, RTC service in Australia is quite a challenge.
Tim: [00:18:06] Yeah. So, that this is this usable over satellite.
I mean, you know, bandwidth aside, does the latency cause that, the interaction to be too difficult.
Sylvia: [00:18:18] Well, satellite isn't the same as any. one satellite isn't the same as the other. So we've got some new satellites, and for whatever reason, they seem to be providing better, delays and, and more reliable connectivity where some of the older satellites, are not just oversubscribed, but also, seem to be introducing larger delays.
So, any connection you have over a satellite, you have to deal with the delays. and, as, as humans, we, after a while, we do get used to that. the web RTC still works over satellite. No problem. you just have to make sure you don't disconnect, calls when the call set up takes longer because you, because of all the latency that's included.
Tim: [00:19:01] Right. That's quite exciting actually. So actually thinking also about the latency issue, or kind of related to it, are there any kind of feedback mechanisms apart from just speech and video communication? So does the, like do you like move the camera or, or anything else? Like does the clinician control the camera in any way?
Sylvia: [00:19:24] PTZ we haven't implemented yet because I don't think actually web RTC itself can support PTZ. You'd have to have some kind of a plugin installed with the computer to, to interface with the devices. Although, I must admit, I, I haven't really analyzed this well enough yet. But, we do make extensive use of the data channel.
So our, our web RTC application, our, our telehealth application, it goes far beyond, what I call talking heads. So audio and video, audio and video is just. To establish a conversation in a healthcare conversation. However, you need a lot more than just talking heads. You need clinical forms that need to be filled in.
You need, a consent that has to be achieved between clinician and, and, patient. So maybe a clinician might need to walk you through many, many pages of consent form, that you need to sign. you need, you may want a clinical tools. So we've got a project called physio room, which measures the range of motion.
Of a person in a live video call. So it, it finds the, joints in your body and connects them, like with, with, with, colored lines. So you can add line of, yes, this is
Tim: [00:20:44] video analysis.
Sylvia: [00:20:47] Exactly. So you do, we do a video analysis on top of web RTC and we display that back to the a physio, physical therapy, users, because then you can actually calculate the range of motions around certain joints in the body.
And, and there's, there's a whole swag of hundreds and hundreds of tools that you can place into a live video call that can help with the, a telehealth consultation. And in fact, that's actually one of our strengths working on these, these, clinical tools.
Tim: [00:21:19] So I'm thinking about, like applications for this and, okay.
I have friends on a small Island in the Pacific, and like, there isn't enough population to, to have any sorts of medical specialists present. You know, the, there, I think there's like one doctor and two nurses for the whole Island. So
Sylvia: [00:21:38] that makes a lot of sense
Tim: [00:21:40] that the sort of kind of target audience
Sylvia: [00:21:42] for this.
It is one of the target audiences. Indeed. that could completely work. so particularly you will have nurses and the GP that, you know, have a, a broad understanding of, of everything, but not, not a lot of depth. So if there's any special kind of, accident happening or, a, a, a virus that they've never seen before, you know, they might want to get expert advice.
so in that instance, you could, you could say that, the clinicians on the Island could have connections with other clinicians. or alternatively, your friends could also get a phone and, and, and find a tele health clinician directly through, through that.
Tim: [00:22:27] So you mentioned both phone and computer, which is your kind of preferred, vehicle for this at the patient.
And I'm assuming the clinician always use a laptop, but maybe I'm wrong there as well.
Sylvia: [00:22:41] No you're quite right. So mostly what we see is the clinicians using laptops. sometimes they're in a hospital also, so it's a desktop computer. and mostly we see patients using phones or, a tablet.
indeed, mostly phone. but sometimes you'll find patients being on a laptop and you'll find a clinician who's traveling between places being on an iPad or on an, on a. On a phone as well, so it doesn't really matter to us. we've built our app, our application, so it adjusts to the screen size, and can usually work quite well.
of course, clinicians will have to deal with the limited screen size on smaller devices, and we don't really recommend the use of the smallest screens for, for clinical assessments. But, sometimes that's what's required. You know, when you're talking, for example, when you're having a mental health consultation, all of the clinical tools and photos and things like that aren't quite that important, so it can still work.
Tim: [00:23:38] Right. So where do you see this going? I mean, you, you, you've said kind of. Rural Australia is like, your, your starting point, where, where else do you, is it, is it something that could happen in Africa or, or you know, or, or do you see it expanding to Europe? How do you, how's it going to evolve?
Sylvia: [00:23:59] Yeah. Look, pave here could be used anywhere. Really. Africa is probably a little bit challenging from the point of view of bandwidth. and connectivity. we, we know that telehealth is already quite widely used in the U S but mostly it's, it's not so much direct to patient. It's mostly between hospitals also still there.
So I think we still, we have had an opportunity to enter the U S market. We have an opportunity to quite possibly enter into the European market. but to be honest, we haven't really fully covered the Australian market yet either. We, we've only just scratched the surface. And what's happening in Australia right now is that a reimbursements through Medicare, are still quite limited, but it is currently changing.
Just this month, we got, the first reimbursement for GPS. Into rural areas, so they weren't able to be reimbursed before via telehealth. That's now new. And so a lot is happening in this space right now. So, we, we still have a way to go before we really need to, need to expand into other countries
Tim: [00:25:07] in, you mentioned, doing.
Analysis of the video, for, you know, joint movement and things like that. Is that a growing area or in terms of adding tools to kind of AI machine learning type tools to, to the video processing?
Sylvia: [00:25:26] Yeah. Look, that's certainly an area where I'm at that still in the beginning of, of development.
and that's across the planet. There's lots and lots of, smaller, a mobile app, mobile apps in development, in health care. Each one with a focus on a particular. health specification, be that wound analysis or, pain analysis by just looking at your face. or anything else that's, that's more form related, asking patients, some questions that would then analyze with artificial intelligence, what their, their health status is.
That certainly all still in development and could all be included with coviu in, in a telehealth situation. we, we are opening up our, interface to, of, of, you know, putting add ons like that into our calls. these clinical tools. We're opening that up to others and we're quite happy for other people to develop such clinical tools as well.
We're still a fairly small team, so, it's not, it's not quite as simple to integrate with us yes. Yet as we wished. but that's certainly one of the big plans for the future.
Tim: [00:26:37] So where do you see those, those machine learning, AI apps running? Do you see them running on the phone or do you see them running on the clinicians PC or do you see them running in the cloud?
Sylvia: [00:26:50] very good question. A lot of these algorithms, particularly the machine learning algorithms are probably too heavy still for the, for the, client side, particularly when you've got a phone. So, a lot of the analysis will continue to happen on the back end on a server. I think. So we will be sending off, at in, in our instance, we are actually sending off the video to a server for analysis and then we get back.
The results. And then we superimpose that on the client's side over the top of the video. as we know computers, are always improving in. in, in, in speed and memory size and all those kinds of things as those capabilities. So I actually think it will be, it will be a couple of years, maybe 10 years or so before we, we will be able to run machine learning and AI in real time on phones and, and on, on client side devices.
It won't be too long. even in a browser, I mean, in the browser right now, it's still, bit handicapped because you don't get access to the kind of, GPU power and everything that you get on, on a. on a, on a desktop application, so, and particularly API APIs. So there's still a lot we can do in that space.
I think, that the standards committee could actually look into that space a bit more and see whether there's things we can do to, IP APIs we can develop in the web browser to make machine learning and video analysis easier to do. That could be something to, to look at actually.
Tim: [00:28:24] Okay. No, that's, that's interesting.
We should, we should talk about that. And actually, I mean maybe finally we should talk about standards. cause that's kind of how we, we met. like I, I'm really interested in the, in the ability of standards bodies to form a consensus. I think that process is really, really interesting and undervalued.
so it was kind of, I'm curious to know whether you've kind of got. Well, you've got more experienced than me in that field. Is that something that you've seen happen and have you got any sense around
Sylvia: [00:28:56] it? Wow, that's a big question.
Writing standards is nontrivial really is. you have such a vast, complex number of participants to deal with that. It always amazes me about the high quality of, of work that actually evolves out of these kinds of processes still. and that's because you get, you get outstanding people involved and you just get.
The best, the best outcomes by, having outstanding people discuss and really fight over details with each other. at that, that brings out the best in that technology can be sometimes. Sometimes it can also be a hindrance because it takes far too long to come to a conclusion and to come to, to make progress.
but oftentimes you get pretty impressive decisions being made by a large committee. now. That all works as long as the committee is technically focused and there is no political agenda behind it. And, and no, no, no. Background, thinking about, you know, how one company can get an advantage over another company, et cetera.
but yes, so writing standards is, is a, and analyzing the whole human processes that happen around that is really quite interesting. you see the people that are running the standards, that are writing the standards, that are wanting the best from a technology point of view. Then you see the users.
That are using, the technology that come in with their requirements, and that often agree with the, with the people that write the standards in, in the content that should be in there. And then you come With the another whole set of different, users, which are the people that have to implement these standards and these, these use cases, and they may have completely different understanding of how the world should work to the rest.
So it can be, can be quite a big fight getting. Getting everyone on the same page and understanding what they use, what they're all talking about, and oftentimes it's just a misunderstanding that doesn't, that stops something from making a progress. So yeah, it's really fascinating space to be honest.
Tim: [00:31:13] Yeah, and I mean, I'm, I'm very interested in how those standards like are really taking, I mean, combination of standards and open, open source really are taking over the world, but certainly the compute space. And I think that like understanding how these processes work and, and, and, you know, understanding how they, they form agreements is really like, there's a, there's a doctoral thesis in that somewhere.
Sylvia: [00:31:41] Yeah. Consensus processes between humans. Yes. Yes, definitely. Definitely not a technical field. Definitely not something I'm an expert in, but I'm always fascinated how it happens.
Tim: [00:31:54] So I, I've got one final question, which is around the costs that, do you see this as driving down costs for, for, for patients, or is it purely about allowing accessibility that wouldn't otherwise be possible?
Sylvia: [00:32:10] All right. Back to telehealth and telemedicine. Yeah. so cost-wise, it's. They, they've been multiple studies around the cost of telemedicine and most conclude that it is cheaper than in person consultations. there's been one or two studies that I've seen that have claimed that telehealth is just creating more work than less work.
and that would be where, you know, you have someone doing a remote assessment, and then saying, Oh, sorry, I can't help you. You really have to come in and see me in person. so obviously there's certain, consultations that cannot be done via video that, that you have to do in person.
however. I think in general there's a large amount of consultations that could be done via video quite perfectly and quite perfectly fine with the right in the same kind of outcomes as in person. And, the savings we see is not really. In the cost of delivering healthcare. It's in everything else.
people that don't have to travel, spend less time on the road, so can, can continue to do more work. They don't have to take the whole afternoon off. They just sit in a, in a room at work for half an hour to do their consultation. people that don't hit the road and don't have to travel to see a clinician have less accidents.
they. they pollute less, you know, their savings across the board for everyone. clinicians that don't have to actually be at their office to hold the consultation. They could be holding a consultation from wherever they are. It could be there at a hospital and they can't make it to their clinic because they're, they're in a surgey that's been taking longer.
They can still hold the consultation online from the, from the hospital. It's reducing stress. On the clinicians, it's reducing stress on the patients. It's reducing pollution. It's reducing the number of hours on the road. So overall, from a, from a whole of a society point of view, telehealth is definitely saving us money and saving us, saving us a lot as humanity.
So I think it's, it's definitely part of the future of healthcare.
Tim: [00:34:29] Cool. That's great. So if you could like, send me any links you want me to include in the, in the what we lovingly call show notes, so that they come alongside with, with anybody who wants to read up more on, on the, you know, on the general topic or specifically on what you've been doing that be great.
And I'm sure, and I will, we do a transcription of this and, I not actually sure exactly when this will come out a few weeks time anyway. we do a transcription and then put it online and make a little bit of a song and dance about it going live, but not, you know, it's every couple of weeks basically.
So. Sure. We'll see how that goes. Well, thank you so much for your time.
Sylvia: [00:35:08] I do appreciate it. You get enough out of it.
Tim: [00:35:11] Yeah, yeah, yeah. Like I said, it's, it's really about like introducing people to a topic they've never thought about. And if you can sort of give them a sense of the space, then people will go off and do their own research and it may take them like six months to get round to it, but you know, it suddenly becomes relevant, something they're doing and they go off and look it up.
Sylvia: [00:35:32] Very cool. Now I just have to find the link to your podcast, so if you could send to me that, you know, I can, I can prepare a show notes that, that are appropriate for it.
Tim: [00:35:43] Okay, great. I'll do that. I'll drop you an email in a minute. Lovely. Cool. Very much
Sylvia: [00:35:48] awesome. Yeah. Yeah. Nice to talk to you.