- On May 6, 2020
- May / June 2020
If necessity is the mother of invention, then COVID-19 has been the catalyst Australia’s health system needed to embrace medical technology.
THE HEALTH system’s acceptance and use of telehealth went from zero to sixty almost overnight.
Pre-pandemic, most medical professionals focused on delivering healthcare via face-to-face consultations, and there was considerable resistance to adopting new patient interaction technologies. While useful for rural and remote healthcare and after-hours service, telehealth was used by a minority. The barriers to using telehealth pre- COVID were multifactorial. For medical professionals, telehealth presented a risk. There was a fear they might miss something if the patient wasn’t physically in front of them – if they couldn’t see them or touch them. Doctors worried that care provided via telehealth would be inferior and patient outcomes would be poorer as a result.
There was also a gap in knowledge – doctors aren’t formally trained to use telehealth.
What questions do you need to ask patients, how do you conduct a patient examination, what red flags should you look for?
And finally, there is the challenge of implementing this technology into your practice. What are the new telehealth MBS items and who can use them? Can patients assign their MBS benefit without a physical signature? Do providers need to be in their regular practice to provide telehealth services? Can doctors mail, email or fax prescriptions and referrals? And what technology platforms should you choose?
There was also significant learning curve on the patient side. And while many embrace the convenience, there is a certain hesitancy that comes with any departure from the norm.
These practical concerns frustrated and flummoxed many in the early days of implementation.
So What Changed?
The threat of a deadly virus brought telehealth into focus very quickly, and within weeks of COVID-19 landing in Australia both doctors and patients looked at ways of reducing their risk of infection. Almost universally, people began saying this is the future of healthcare.
The other huge driver for the adoption of telehealth was funding. In late March, the Federal Government announced expansion of Medicare subsidised telehealth services for all Australians.
In doing so, the Commonwealth recognised the value of telehealth services as a means of keeping medical professionals safe while allowing patients self-isolating or in quarantine to still access medical care.
Prior to that announcement, the MBS item only applied to people with a confirmed case of COVID-19 or those in isolation, along with some groups such as people over age 70.
The changes meant telehealth services were expanded to include GP services and some consultation services provided by other medical specialists, nurse practitioners, mental health treatment, chronic disease management, Aboriginal and Torres Strait Islander health assessments, services to people with eating disorders, pregnancy support counselling, services to patients in aged care facilities, children with autism, and after-hours consultations.
In a COVID world, the obvious benefit of using telehealth is the ability to reduce transmission of the virus – making clinical appointments safer for clinicians and patients. But there are other benefits as well.
Digital Health CRC held a series of webinars in March and April with panellists from around the country and overseas, including Professor Trish Greenhalgh from Primary Care Health Services, University of Oxford.
“The worst way to do this is to think about it as installing a piece of technology. The best way to do it is to think of it as improving a service,” Prof Greenhalgh stated.
Her research indicates patient satisfaction with telehealth is quite high. For patients – particularly those in rural and remote locations – telehealth cut down valuable travel time to appointments.
“Having a bit of time to prepare for anything that you’re about to see face to face and having a think about what that is, benefits both clinicians and patients. You may not be able to complete consultations on telehealth alone but starting all of them with telehealth can lead to enormous benefits. Sometimes patients present with something you’ve never heard of or a cluster of symptoms that are difficult to sort through and actually having some preparation prior to seeing them is really helpful. You may not be able to do everything on telehealth, but as a baseline it’s an excellent way to practice.”
Because telehealth is less time consuming, Dr Triska said he can have more regular contact with patients. As a result of this, his practice has experienced a reduction in safety incidents.
Sydney general practitioner, Dr Amandeep Hansra, who appeared as a panellist for the Digital Health CRC webinars, has been in the telehealth space for close to a decade. She said her practice uses telehealth as a triaging tool.
“There are some things we can complete virtually and there are some things we need the patient to come in for. But in a COVID world, we need to be adequately prepared for those patients. We are able to organise our days much better when we know what’s coming through the door.”
And for patients with mobility issues, following them up more regularly via phone or video provides a more holistic service and gives them better access to healthcare.
The biggest roadblock for many practitioners is around the diagnostic challenge of not being able to physically examine a patient and the fear that they will miss something.
According to Dr Hansra, “If you look at international literature there is no evidence that telehealth services have worse outcomes than face to face healthcare. [The research has shown] if you put in good processes and good principles, you can mitigate for a lot of the risk that people are fearful of.”
Telehealth experts suggest doctors have a plan or series of standard questions they use. For example, ‘Is the patient happy to be contacted in this way? Are they in a space where they can discuss their health issue?’, etc.
Some consultations can be conducted over telephone, while others are better suited to video. According to Prof Greenhalgh, there is a surprisingly large amount of examination that can be conducted via video. She indicated that eyeballing patients gives doctors quite a bit of information. However, if the consultation is being conducted via phone, the doctor will have to ask more questions to give them a better idea of that they aren’t able to see, eg. ‘Are you ok to talk to me?’, ‘Are you feeling all right?’
There is also the opportunity to get clinical information from the patient if they already possess devices such as thermometers, blood pressure monitors, etc, that can be used to assist the doctor during the consultation.
And in some cases, a better patient experience can be achieved through email. Dr Triska said, in his experience, a lot of mental health patients prefer email or texting.
“A lot of people talk about missing visual cues from face to face. But we find a lot of patients will divulge more over email than phone or video. A lot of deep dark secrets have been sent our way via messaging services rather than video or phone… Just pick your battles,” he added.
Telehealth experts agree not everything can be done remotely. There are a significant portion of things that are just not possible to do without a physical examination.
“There is a scope of what can be done. And if you know where your limitations are you can perform most things safely. As long as you know at what point does this patient need a face-to-face consultation,” Dr Hansra said.
Another potential challenge for practitioners and patients is around use of the technology itself.
There is a fear that certain groups will have greater difficulty in accessing care via telehealth, particularly older patients, or patients with limited English.
However, telehealth doctors indicate they haven’t found technology to be the barrier that had feared it would be. Even patients in their 80s have had almost two decades of experience with the internet and many are adept with using video platforms. And for those who aren’t, the telephone is always a good option.
For patients who face a language barrier, doctors may need to find assistance with an interpreter or a family member the patient is comfortable with to assist.
Lastly, in terms of barriers, the rapid shift to telehealth has exposed some of the infrastructure changes the system needs to undertake to make delivery of care more seamless. These include scripts, pathology referrals, and specialist referrals.
To make it easier for practitioners to adopt telehealth, there has been a relaxation around use of consumer level technologies.
However, patient privacy, data protection and security remain a concern. Further guidance around what is safe, what meets the Australian privacy principles and what is secure needs to be provided.
Doctors are encouraged to do their research and steer away from free platforms. Telehealth experts suggest speaking to your existing vendors and aligning yourself with a provider that offers services in line with what you want to do. Another practical idea could be to invest in a platform used by your colleagues, who can help you troubleshoot any problems that arise.
The Digital Health CRC webinars had thousands of doctors sign up, which is perhaps demonstrative of how eagar doctors are to use telehealth.
But in the rush to reduce transmission of COVID through telehealth, the health system leaped over a few necessary steps to really get the most out of this technology.
Post-COVID, the use of telehealth will largely be dependent on whether it continues to be funded. There is a concern that the cost to the Commonwealth could blow out, which may result in a significant paring back.
At that point, however, consumer and clinician acceptance of telehealth may spur demand for this technology.
According to Dr Hansra, “We have been given a unique opportunity to show we can maximise the potential of telehealth and do it safely and effectively. In essence we are ‘on trial’. If we do the right thing I think we can certainly make an argument that telehealth needs to be part of our normal care delivery. Not everything can be done via telehealth but there is a lot that can be done, and it is important that we have those options and that our patients are given that choice too. I would love to see it be here for the long haul but I anticipate we will need some analysis first, of how we have managed our trial run. In the end it should all be just healthcare no matter how we deliver it.”
Based on feedback from medical professionals, NSW Health introduced a temporary measure on 17 April which allows for image-based prescriptions in NSW. Medical practitioners and nurse practitioners are now able to issue an image-based prescription for emailing or faxing to a community pharmacy. The prescriptions do not need to be followed with a hard copy and can be issued with repeats.
The measure is restricted to Schedule 4 medicines, except those in Appendix D. S4D medicines and Schedule 8 medicines are not included in the temporary arrangements. A prescriber may still direct a pharmacist to dispense S8 and S4D medicines by telephone, email or fax, and the paper-based prescription must be sent to the pharmacist within 24 hours.
The measure was introduced to allow for better integration of prescriptions and supply of medicines with the telehealth reforms.