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Unpicking some key challenges for the telehealth revolution ahead

Melissa Sweet
Melissa Sweet, with Cate Carrigan
Wednesday, March 25, 2020

COVID-19, Health reform, Workforce matters, Primary healthcare, Rural and remote health, Telehealth

The COVID-19 crisis is driving changes in health services at a pace that was previously unimaginable, including in the delivery of consultations by telephone and video conferencing, or telehealth.

The Federal Government announced this week that it is working with health and medical groups to expand telehealth availability for all patients, with or without COVID-19, to see GPs, medical specialists and allied health practitioners.

However, critical barriers and issues remain to be resolved, according to experts who contributed to an online webinar last night (24 March), presented by ABC broadcaster Dr Norman Swan.

The webinar, titled The roles, relevance and risks of using telehealth in a crisis, was hosted by the Digital Health Cooperative Research Centre in collaboration with Curtin University and La Trobe University, with more than 3,400 registered participants. Watch it here and see a summary below.

The telehealth push comes amid mounting concerns globally about the COVID-19 toll on healthcare workers, as well as concerns about equity of access, especially for patients in rural, remote and regional areas.

One of the webinar presenters, Professor Trisha Greenhalgh from the University of Oxford, made a powerful point about the urgency of implementing telehealth.

Three junior medical officers were currently on ventilators in London, she said, all under the age of 30. Face-to-face consultations had suddenly become much less safe, she noted.

Telehealth is also a focus in the first episode of our new #CroakeyVOICES podcast, which includes an interview with Dr Centaine Snoswell, the Centre for Health Services Research, University of Queensland. Also featured is an interview with Chips Mackinolty, the executive director, Researcherenye Wappayalawangka, Central Australia Academic Health Science Network.

Warm thanks to journalist Cate Carrigan for launching the new podcast channel – also follow on Twitter: @CroakeyVoices.

Government announcements

The announcement of telehealth’s wider roll out was made jointly by Minister Greg Hunt, together with Australian Medical Association president Dr Tony Bartone, Royal Australian College of General Practitioners president Dr Harry Nespolon, and Michael Kidd AM, Principal Medical Advisor, Department of Health (see 23 March statement).

In the interim, from 23 March, GPs and other health professionals at increased risk from the novel coronavirus are authorised to use telehealth item numbers, to use telehealth for all consultations with all their patients.

This includes health care providers who are:

aged at least 70 years old
Indigenous and aged at least 50 years old
pregnant
a parent of a child under 12 months
immune compromised
have a chronic medical condition that results in increased risk from coronavirus infection.

The joint statement said:

“This change will help protect the most vulnerable members of our health care workforce, while allowing them to continue to provide much needed medical care and advice to their patients.

It is expected a more comprehensive telehealth whole of population model of care and the detail of telehealth operations via phone and video will be confirmed by the end of this week as Stage four. This will include mental health and allied health consultations.

It is important that this is done carefully to ensure these new items do not have unintended adverse consequences for patients or the health system, while allowing general practitioners and medical specialists to continue to work during the pandemic, using phone and video where clinically appropriate.

We recognise telehealth is not appropriate for the management of all health care problems and in many cases face-to-face consultations will still be needed. It is imperative Australians continue to receive the high quality medical care and advice they expect and deserve from their health care providers. We cannot risk a reduction in the standard of medical care provided to the people of Australia.”

For details on when telehealth items can be use: www.mbsonline.gov.au

RACGP News reports that GPs will be able to bulk bill phone or video consultations with all patients as of 30 March, with eligibility criteria to include all GPs, specialists, and mental health and allied health professionals.

Professor Michael Kidd said: “This has been one of the most significant changes we’ve seen in Australian general practice in my working lifetime of 35 years.”

Key points from webinar

(Watch in full here).

General concerns were raised about the need to enable access to electronic prescribing and ordering of pathology, as well as electronic access to patient records.

Despite the new announcements, it’s clear that funding barriers remain to telehealth’s wider uptake.

Professor Trish Greenhalgh, Primary Care Health Sciences, University of Oxford, UK

Don’t think of it as installing a technology; think of it as improving a service, and address the organisational, logistical, cultural changes and work flow issues.
Work with those who have concerns. They may be legitimate, such as concerns about impact on clinical and professional standards. Get everyone on board.
A surprisingly large amount of physical examination can be done by video, starting with eyeballing the patient to see if they are sick or well, and assessing respiratory distress and breathlessness. Don’t ask, ‘are you breathless?’, but ‘what can you not do today because of your breathless that you could do yesterday?’.
Many, many patients feeling breathless are just anxious and need reassuring. The visual presence of a doctor or nurse is very reassuring.
You need a protocol and someone to run the phone to deal with the large number of worried well. The video is for those who are more than usually anxious and need a clinical assessment.
Research on patient satisfaction re telehealth is skewed as most patients involved are a highly selected population, ie those who support telehealth anyway because they are choosing to use it. Patient satisfaction tends to be very high because of reduced travel time etc.
Stressed the importance of managing co-morbidities at this time.
Sort out electronic access to medical records: I am absolutely horrified that you don’t have access to your patients’ records if you are not in the building. That for me is the scariest thing I’ve heard in the last 85 minutes.
Telehealth consults result in shorter consultations than face-to-face, especially after you’ve been through the learning curve of the practicalities.

Dr Amandeep Hansra, GP, Bondi Doctors, NSW

Telehealth has to be supported by a funding model that works for general practice in Australia.
Clinical governance is critical. It’s hard to implement something rapidly; remember this is quite a shift in how we deliver care, with inherent risks.
Practitioners need training so they understand what they might miss via phone or video conference.
It’s critical to fully document a systematic approach. These calls/consultations need to be documented just as well, if not better than face-to-face consultations. It’s important to give disclaimer about what to do if they get worse.
Next week RACGP will put out guidelines about how to set up processes for good clinical care in the age of telemedicine, so look out for those.
Don’t assume old people will not be IT literate; many have been on Skype for years with grandkids. They may want to do the consult with a family member.
E-prescribing has to be rapidly accelerated, also electronic ordering of pathology.

Dr Neale Fong, WA Country Health Service Board Chair, and medical practitioner

WA CHS has been on a telehealth journey for the last 7 or 8 years to improve country people’s access to care in emergencies.
More than 100 locations throughout WA have access to emergency telehealth; in the last year, there were 25,000 emergency telehealth presentations and many lives saved. The service is now being trialled in an Aboriginal Medical Service in the Kimberley.
Plus, last year over 20,000 outpatient presentations for all different presentations via telehealth, including chemotherapy and mental health. We are on a journey to use video conferencing telehealth much more than we do already.
Most patients still come into their local health services for the telehealth consultation; the next step is for us to move much more into home and community settings.
Still collecting data on impact, but benefits include convenience, the saving of time, people not having to travel, either to Perth or regional centres.
Connectivity in some remote areas remains a barrier.
A next step will be ensuring consultations are recorded and entered automatically into records.
The COVID experience will lead to more innovation, creativity and determination to do things differently going forward.

Karrie Long, School of Nursing and Midwifery, La Trobe University and Director, Nursing Research Hub, The Royal Melbourne Hospital

Many of our telehealth patients are from across Australia, from Darwin and Tasmania.
It is not about the IT, it is about human implementation for a human service; our service works out what clinicians need to make this happen and what patients at home need.
We are looking at maintaining a service to our chronic disease patients in outpatients during the COVID period (ie to prevent their condition worsening while services are under intense demand).

Dr Daniel Stefanski, Staff Specialist Infectious Diseases Physician, Queensland Health

Existing relationships are important. The relationships that his team has developed with remote practitioners in recent years will be very important; our responses during the COVID period will be led by them.
An important point, especially in COVID, is that there is no mechanism for any doctors to be paid for remote consultations for an inpatient in a hospital, or for hospital in the home.
We are going to see a huge demand for a funding model to be able to fund specialists and rural GPs; this is a policy imperative that has to be discussed right now.

Also, see this webinar hosted by the Australian College of Rural and Remote Medicine on 24 March, with Dr Shannon Nott.

Abstract: The current coronavirus (COVID-19) pandemic is again reminding us of the importance of using telehealth to deliver care, especially as means of reducing the risk of cross-contamination caused by close contact. For telehealth to be effective as part of an emergency response it first needs to become a routinely used part of our health system. Hence, it is time to step back and ask why telehealth is not mainstreamed. In this article, we highlight key requirements for this to occur. Strategies to ensure that telehealth is used regularly in acute, post-acute and emergency situations, alongside conventional service delivery methods, include flexible funding arrangements, training and accrediting our health workforce. Telehealth uptake also requires a significant change in management effort and the redesign of existing models of care. Implementing telehealth proactively rather than reactively is more likely to generate greater benefits in the long-term, and help with the everyday (and emergency) challenges in healthcare.

Virtually Perfect? Telemedicine for Covid-19

https://www.nejm.org/doi/full/10.1056/NEJMp2003539

Brief summary of some of key points: Authors, based in US, suggest telemedicine could be used to provide “forward triage” – obtaining symptoms and travel histories over the phone, relieving some of the pressure on hospitals/ED. One of the main barriers to this working successfully is “coordination of testing” – those using telemedicine to triage need to have appropriate methods of testing, or patients still end up being referred to ED/testing clinics. Interestingly, they point out telehealth could also be an option for health care workers who become infected, allowing them to triage from home. Other barriers include cost/Medicare etc.

Novel coronavirus (COVID-19): Leveraging telemedicine to optimize care while minimizing exposures and viral transmission

http://www.onlinejets.org/article.asp?issn=0974-2700;year=2020;volume=13;issue=1;spage=20;epage=24;aulast=Chauhan

One key statement: “Based on the above rationale, the availability of TMS can become a critical need for populations and patients affected by the COVID-19 infection, especially when under active quarantine. Enabling patients to consult a health-care provider via teleconferencing, in real-time, to allay one’s fear and anxiety, seek advice regarding their routine health problems, and learn self-care, all become critically important in the setting of hospitals and clinics being overwhelmed with more acute complaints.”

“In summary, the WHO and other global health care organizations should take into account and issue directions to countries to adopt and strengthen TMS services that will augment and optimize the planetary effort to extinguish the COVID-19 pandemic.”

See Croakey’s previous articles on telehealth