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Amid the rush to telehealth, let’s ensure we address these cautions and questions

Introduction by Croakey: Telehealth was a recurring theme when I recently asked a range of people, when researching this article for The Guardian, What opportunities for positive change in healthcare have been created by the pandemic?

This is not surprising given the rapid uptake of the temporary telehealth items introduced as part of the pandemic response, with more than 9.3 million telehealth services provided via the Medicare Benefits Schedule (MBS) since 13 March, according to Federal Health Department figures shared with the sector last week.

However, researchers at Macquarie University caution in the article below that there are many questions and issues to consider and investigate further.


Amy Nguyen, John Cartmill and Sarah White write:

One hundred years ago the Russian literary theorist Victor Shklovsky pointed out that ‘strangeness’ could make a routine experience fresh again.

In this way, telehealth, which includes telemedicine, is strange for many of us, and that ‘structural challenge’ invites and facilitates reflection on what we might otherwise take for granted in medical consultations: equity, effectiveness, health literacy, safety, quality, risk, privacy, even the fundamental nature and purpose of communication in consultations.

It is worth addressing some of the strengths and weaknesses of telehealth – particularly with regard to an initial consultation – while its use is novel (note, the authors acknowledge that telemedicine is not new and that there are many experts in the field).

Equity

Telemedicine can be wonderful for those with limited mobility or means to attend a consultation. On the other hand, a patient (or doctor) with a hearing or vision impairment might struggle. As with any complex phenomenon, equity in telehealth is vexed; there are winners and losers.

It would be naïve to think that most people have, or have access to, a telephone, and a safe, private place with uninterruptable time, to talk.

Plus the more hidden inequity is for those patients who would benefit from a physical examination; a blood pressure check, a pulse or digital rectal examination.

Training

There is no shortage of telehealth guidelines; these are laudable and important but invariably technical.

We acknowledge the importance of good teleconference hygiene (lighting, camera angle, audio) but contend that the essence of the telemedical consultation is not the ‘tele’ (the distance or the technology), but the ‘consultation’ – and there has been little training around this.

Communication

We tend to take the phenomenon of communication during consultations for granted and it seems to be assumed that skills and experience developed over a career of face-to-face consultations will automatically transfer to delivery via telephone or video link; however, that is not necessarily the case.

Differences in communication styles and strategies employed during face-to-face and telehealth consultations, and their subsequent effectiveness, need to be explored in contextual studies.

There is an assumption that traditional communication practices translate easily from face to face consultations to remote delivery models.

However, there are norms and practices for telephone conversations that could be at odds with a medical consultation; the telephone is associated with more trivial subjects, with convenience, with multitasking. These telephone habits and expectations can persist and have the potential to devalue a consultation.

Not all medical consultations ‘weigh’ the same; an initial consultation is likely to be more consequential than a follow up or a simple request for a referral or repeat prescription.

Breaking bad news is another unique challenge with telehealth, with studies showing this can be difficult to do from a distance.

Effectiveness

The talk of a future where telehealth assumes an increasingly prominent role, even after COVID-19 restrictions are relaxed, underestimates the value of the ‘bandwidth’ of face-to-face, real time, same room conversations.

We wonder if it might be easier to miss a ‘cry for help’ when it is made from a distance.

Linguists and conversation analysts place great significance on ‘embodied’ components of communication; those signals and signs and the interplay between talk and embodied action. Additionally, distinct from faces and words alone, a shrug, or slump of despair can so easily be missed.

Beyond that, “seeing” the patient is often cited as an important clinical skill that develops through years of experience – assisting the assessment of the patient beyond what they describe in words.

Safety, quality and risk

We suggest that some behaviours or errors associated with the innate human factors and cognitive biases of automatic functioning that beset normal consultations can be amplified by increased distance and reduced bandwidth. And nor are there ameliorating opportunities that we otherwise rely on.

There is seemingly less opportunity for ‘one last thing’ or ‘did you tell the doctor about…’ when the close of the consultation, the signals of disengagement appear to be so abrupt.

Health literacy

There is less opportunity to assess and adjust for patient health literacy.

It is technically possible to share a screen with some technologies, but it is much more of a nuisance than simply drawing a picture on the back of a piece of a paper, for example. Nor are the subtleties and nuances of linguistic ‘correction’ supported.

Privacy and confidentiality

Video conversations and meetings are not encrypted, at least not yet.

Perhaps an expectation of guaranteed privacy is overkill, who would really be interested anyway? We suggest that depends on whose haemorrhoids they are.

This also becomes an issue in shared homes, particularly for those experiencing domestic violence or very sensitive conditions.

Is the person on the end of the line even the patient or person they say they are, or who you think they are?

Sustainability of consultations

Telehealth is not as efficient as it seems at first glance; it is much more than simply making a phone call or hitting a video link.

Mundane tasks that are automatically assumed by a patient in attendance (taking a prescription or a booking form with them for example) must be taken on and coordinated by the practice. Postage, staffing, record keeping, closing loops – all assume greater importance and it costs more.

Until recently, telehealth could only be bulk billed for certain situations and while that has changed, there is a perception that a telephone consultation is simply not worth as much as the real deal.

Telehealth has been deployed rapidly, effectively and with some prospect that it may be retained beyond the COVID-19 restrictions.

While bringing with it many immediate advantages, its suitability for the long term requires more thorough research.

Authors

Dr Amy Nguyen is Research Fellow with the Australian Institute of Health Innovation, Macquarie University. @DrAmyDNguyen

Professor John Cartmill is Associate Dean Clinical, Faculty of Medicine, Health and Human Sciences, and Professor, Surgery in the Department of Clinical Medicine at Macquarie University. 

Dr Sarah White is a Senior Lecturer in Professional Practice in the Faculty of Medicine, Health and Human Sciences at Macquarie University and the Deputy National Representative for the International Association for Communication in Healthcare in Australia. @DrSarahJWhite