Introduction by Croakey: The long-awaited access to telehealth consultations in the coronavirus pandemic has been broadly embraced by patients and health care providers, though it is not without concerns.
In the UK, the “telemedicine revolution”, which has come much faster than the NHS Long Term Plan anticipated, has been critical to continuing healthcare provision during the crisis but it has come at a cost for many of experience “digital exclusion”, according to this recent article in the BMJ.
Amid other concerns, the Royal Australian College of General Practitioners (RACGP) last week called for an urgent overhaul to telehealth and telephone consultations to ensure patients “steer clear of corporate telehealth pop-ups which have proliferated” amid the Federal Government’s expansion of Medicare-subsidised telehealth and telephone consultations.
The RACGP had long supported expanded telehealth and telephone consultations, which have helped decrease the risk of spreading COVID-19 to patients and practice staff and made care more accessible for vulnerable patients, said President Dr Harry Nespolon.
“But we have been deeply concerned to see the rise of more and more pop-up telehealth businesses offering low value medical services. These businesses promise a ‘quick fix’ for patients but there is no commitment to the ongoing care of the patient,” he said.
The RACGP is urging that telehealth services should only be accessible to patients through their regular GP, saying the evidence is clear that patients who have an ongoing relationship with their GP report higher levels of satisfaction and better health outcomes.
In the article below, previously published at John Menadue’s Pearls and Irritation blog, Professors Peter Brooks and Brian Oldenburg and Dr Stephen Duckett provide a road map to this “exciting time in health care”.
Peter Brooks, Stephen Duckett and Brian Oldenburg write:
Telehealth is not new in Australia but Covid-19 and the new Medicare item numbers have stimulated its rapid adoption across the country.
It is clear patients like it. They do not need to expose themselves to potentially dangerous environments such as hospitals and clinics.
It saves them time whether in rural or urban environments and it delivers care – and patient education, in their own environment.
Appropriate models of ‘virtual ‘care delivery need to be refined and appropriately funded with Medicare item numbers that are robust and include a wide range of services and individual health professionals.
Telehealth will make a big difference to care delivery around the world with a ‘new’ digitally enabled health workforce needing to be trained.
In Australia we must not revert to the health system we had pre-COVID-19 and we must train health professionals and patients alike to accept ‘virtual’ is just another way of communicating.
Institutionalising telehealth
Of the many changes to everyday life during the COVID-19 pandemic has been the massive growth in billed telephone consultations and video consultations.
The majority seem to be voice or text but the public have lapped up this new way of interacting and getting advice. After the pandemic, the health system – professionals and payers – need to institutionalise telehealth as a valid, useful and efficient part of the new health system.
Australia, especially Queensland with its dispersed population over vast distances, has been a leader in telehealth implementation and research for many years.
The Queensland Telehealth Unit has supported local telehealth initiatives, de-emphasising adoption of the latest technology, in favour of developing systems and processes which make telehealth sustainable within the budgets of local health services, for example, showing that telehealth implementation can reduce patient transport costs met by hospitals.
The University of Queensland-based Centre for Research Excellence in Telehealth supported cutting edge innovation and evaluation to show what worked and what didn’t. And this has helped inform a significant cultural change to adopt telemedicine broadly across Queensland Health facilities.
Other Australian states such as Western Australia have already adopted a plan to convert 30-40 percent of outpatient attendances to virtual consultations over the next few years.
Interestingly other countries have been much more open to embracing telehealth in their health systems. In the US, health care provider Kaiser Permanente said in 2016 over 50 per cent of some 100 million consultations undertaken were by telehealth and the Veterans Affairs system – which provides care to 10 million veterans – used telehealth in over 70 percent of interactions, up from around 10 percent over a three-year period.
It is not that there has been no interest in telehealth in Australia over the past 20 years; rather, it is just that uptake has been incredibly slow and unsupported until the last few months, with the introduction of a range of new telehealth item numbers primarily for doctors and nurses and allied health professionals.
Interestingly, although the traditional telephone was supposed to be the back-up if video were not available, telephone appears to be the dominant medium used with the new items.
Over the past few months many hospitals and health professionals are now conducting more than 50 percent of their interactions with patients ‘virtually’ – and it took COVID-19 to make us change our (health professionals’) behaviour.
Cultural change and leadership required
If these recent sudden changes are to be maintained in the future, it is important that health consumers are also supported in this ‘brave new world’ and that more effort is put into using video and more contemporary technology to manage complex chronic conditions at home.
This change, while enabled by technology, has to be a cultural change – but it will require leadership and the recognition that we need to engage consumers in decisions around the type of health care they want and how they want it delivered.
Telehealth provides a real opportunity for genuine patient participation in clinical decision making and in engaging patients in designing a health system that works for them as well as for health professionals and the payers.
Think, for example, the real savings (financial and time – which also has a monetary value, let alone a contribution to carbon emission reductions) to be gained by using telehealth when it takes around 2-2.5 hours and significant costs for transport and parking to keep a 20-minute health care appointment in the middle of most cities in Australia.
We know the benefits of telehealth to the rural/remote sector – we need to acknowledge them in urban settings as well.
Telehealth can also be used for patient and professional education, for expanding the reach of clinical trials so that those in rural areas have same access to new therapies as those living in our major population centres, home monitoring and many other health related activities including patient education.
The road ahead
As/when we emerge from the current ‘social distancing’ phase, it will be important to look at all of the ways in which health care can be delivered more effectively and efficiently to health consumers by using available technology.
COVID-19 has exposed important weaknesses with our current health care system which we should address and one of those is how we are going to utilise digital solutions including telehealth for the benefit of all in the health system.
Think what a difference this will make to hospitals: they may become smaller and more focused of high technology interventions, as in Denmark and other Scandinavian countries.
The Topol Review provided for Health Education England delivers an excellent road map of what can be achieved by using this technological revolution not just for health professionals but for patients, carers and the wider community.
Use of Chat Bots, AI (artificial intelligence) driven solutions and a range of monitoring devices will all be in the mix.
Importantly these changes will require a significant change in the health workforce, in providing them with technology skills.
We will need the development of new workforce roles:
- digital health technicians and digital health navigators (who will likely be a key part of any health and social support system in the future) to ensure health professionals and patients can connect rapidly with each other at any virtual consultation
- digital health navigators who can guide patients to the information they require to assist them better manage their chronic diseases in a safe environment- their homes and communities. They will also play a role in ‘connecting patient rapidly with tjheir usual health professional providing a greater immediacy of response to the patients health concern reducing stress.
Technology is key, but so is a human interface and this is where navigators can enhance and improve the experience and productivity of the digital health revolution.
It may well be that social distancing will continue into the future and many isolated individuals will have difficulty managing their chronic health conditions, getting their medications, obtaining food, exercising, maintaining their social and family connections, and addressing the increasing issue of loneliness in society.
Many people do not have the digital literacy, knowledge of or access to the tools and resources to help them navigate through these complexities in order to find the required services, resources and supports and though this is improving quite rapidly, digital training for all sectors of the community is very important.
The Navigators, assisted by AI-powered triage tools, deliver personalized care plans to help individuals deal with their social, health and mental health challenges. Tailored care plans comprising community-based solutions can be developed based on an individual’s location, age, education level and health insurance status.
While designed to improve people’s quality of life, Digital Navigators are also likely to save jurisdictions from rising healthcare costs of untreated medical and behavioral health problems.
And in this current crisis they could provide job training coupled with employment opportunities in the burgeoning health sector, playing a role in alleviating the burden of rising unemployment due to this crisis and its significant impact on service industries.
To reap the full benefits of this opportunity to reimagine healthcare, we need a framework that can ensure an appropriate range and connectivity of technologies at both ‘ends’ of the consultation and engagement, and training of staff and patients to ensure smooth facilitation of the experience.
Investment of time and funding to ensure proper patient engagement will help drive success. This will be an investment in health and social care and a very important one for our future of Australia.
This is such an exciting time for health care. We strongly support a wide range of telehealth Medicare item numbers that allow a broad range of health professionals to participate in these technologies with appropriate controls to prevent over-servicing, which so often happens in our health system.
Peter Brooks MD FRACP FAFPHM is Honorary Professor at the Melbourne School of Population and Global Health and Research Lead at Northern Health.
Brian Oldenburg MPsychol PhD is Professor of Non-Communicable Disease Control in the Melbourne School of Population and Global Health and Director of the NHMRC Centre for Research Excellence in Interactive Digital Technology to transform Australia’s Chronic Disease Outcomes.
Dr Stephen Duckett is Health Program Director at the Grattan Institute.
