The all-encompassing COVID-19 pandemic has disrupted the world like nothing before it, yet it’s the pressure on primary health services and public health systems that have been most affected.
With stringent stay-in-place, quarantine and social distancing orders in place, the role of telehealth has never been greater, which has been reflected in the Federal Government providing $100 million of Medicare funding for bulk-billed telehealth consultations.
The telehealth system, essentially video and some telephone consultations between clinicians and patients, could prove to be extremely effective in treating at-risk patients by reducing the possibility of community transitions of COVID-19, while offering a new paradigm of treatment that is potentially more convenient and cost effective.
Although telehealth has been in use in Australia for almost two decades, the take up has not been representative of the system’s potential, but this is changing, particularly in primary health.
The questions we need answers for are: Will telehealth become the new normal for primary care service delivery? And could the disruptive forces of COVID-19 be an opportunity for clinicians and the public to fully embrace its benefits?
Slow start
Twenty years ago, telehealth was primarily used for specialist consultations on an ad-hoc basis, particularly with patients in rural or remote locations. Then the cost of dedicated video conferencing systems was prohibitive – over $30,000 a unit – whereas now, these tools are free (Zoom, Skype, FaceTime etc) if you have a compatible device.
Distance between a clinician and patient may have been the initial primary rational for telehealth, but this is no longer the case, says Professor Anthony Smith, Director at Centre for Online Health at the University of Queensland.
Prof Smith has been researching and designing telehealth services for more than 20 years: “Telehealth has proven to be useful for everyone, regardless of location. We have established telehealth services to support patients living only a few kilometres from their hospital.
“These people may normally find it difficult to attend their appointment because of frailty, other physical or mental health issues, transport costs, or lack of family support. Telehealth technology has changed this significantly.”
Although the uptake of telehealth has been slow and fragmented in Australia, Prof Smith said this wasn’t without good reasons.
“The lack of funding to support the costs of doing telehealth for patients and providers; availability of technical infrastructure, such as high-speed telecommunications and interoperable video-conference platforms; absence of revised workflow procedures; appropriate education and training; limited general public awareness of telehealth; ineffective or no change-management processes, as telehealth is a disruptive process – it’s a different way of providing care.”
Change management
A salient determinant for acceptance of disruptive technologies is effective change management, he said.
“Some clinicians seem to adopt telehealth quickly, while others are resistant. It’s important to consider change-management strategies which support clinicians and patients during this process.
“Learning from experience is important. We often find that once clinicians have been involved in telehealth, the process is much more acceptable to them.
“It’s also important to acknowledge that telehealth is not appropriate for all consultations. There will always be a need for appointments that require a physical assessment or specialist procedure which can’t be done remotely. Of course, the decision to do telehealth should be based on the clinical requirements.”
Telehealth & COVID-19
With the unprecedented disruptive changes due to COVID-19, such as social distancing, there has been a rapid adoption of telehealth, which has validated the benefits of the system for clinicians and patients alike, Prof Smith said.
“Patients can access services more conveniently from their own home. Vulnerable patients, such as those aged over 70 with chronic health conditions, can have a telehealth appointment rather than waiting in a busy medical centre, among other people who potentially have the virus or other communicable health conditions. While clinicians are able to assess and manage patients without the risk of infection.”
Finding the funding
As part of the COVID-19 funding package provided by the Federal Government, amendments have been made to liberate the delivery of telehealth.
“We have seen major changes to Medicare funding guidelines such as the removal of geographical limits and the introduction of special telehealth MBS items for GPs to consult directly with their patients via telephone or video conference, and MBS telehealth items for nursing and allied health services,” Prof Smith said.
“Currently, there is no stipulation on distance which means that a clinician can consult with a patient who is in the same suburb.
“Questions have been raised about the inability to charge a gap fee for primary care telehealth items. This is an issue currently being considered by various professional colleges and the health department.”
Privacy problems
The susceptibility of some video-conferencing systems’ data management and encryption could lead to potential privacy issues. FaceTime and WhatsApp offer end-to-end encryption, while Zoom has ‘incomplete’ end-to-end encryption – in essence, it is not secure. Skype has no encryption at all.
“The issues of privacy and security have to be resolved at the same time we focus on the integration of telehealth into mainstream health services. Many common platforms such as Zoom and Skype are used for telehealth appointments, and while the risks are low, they do need to be recognised,” Prof Smith said.
While privacy via video-conferencing applications could be problematic, Prof Smith says it comes with similar risks to other methods of communication.
“It is important patients are informed of the risks of whatever platform is being used. We have to remember, though, that other communication methods – telephone conversations, email messages and fax transmissions – can potentially be intercepted, but the occurrence is extremely rare,” he said.
“Clinicians need to be trained to use telehealth, including the guidelines around privacy and security.”
Barriers to entry
While the need for expensive, dedicated video-conferencing systems for telehealth has decreased, and the proliferation of smart phones and tablets has made telehealth more equitable, there will still be disadvantaged users.
“Fortunately, we are seeing more widespread access to mobile phones and Internet connectivity across Australia,” Prof Smith said. “However, we must remain mindful of patients who may not have the necessary technology for a telehealth consultation.
“One way of addressing this is by providing telehealth facilities in community health centres, so patients can access these services without the need for extensive travel. As training is important for clinicians, it is equally important to raise awareness of telehealth amongst the general public.
Tele-future
Will telehealth become a staple of primary health care? Although Prof Smith cannot say definitively if this will be the case, he believes its benefits during the COVID-19 pandemic will demonstrate how effective it can be for routine consultations.
“My vision is that we have access to a comprehensive health service which includes telehealth as a routine service modality. There’s no reason to switch off a valuable service which delivers easier access and greater convenience to health services.”
He provided two use-cases where telehealth is advantageous.
- Triaging patients and determining best pathways for care – we should quickly see a proportion of appointments that don’t require physical contact changed to telehealth.
- An opportunity for GPs and specialists to be more connected and improve continuity of care and enhancing training opportunities through shared case management.
Prof Smith said research funding was urgently required to escalate the critical appraisal of telehealth in Australia. Now is the ideal time to compare telehealth with conventional face-to-face services,” he said.
“We need to explore new telehealth-enabled models of care with a particular focus on barriers and enablers; workflow procedures which are replicable; education and training requirements; funding implications and user experience.”
Message for GPs
Ultimately, telehealth’s uptake is dependent on clinicians who believe in the value of it for them, their patients and their practices.
“The more familiar GPs are with telehealth, the easier it is to explain its basics. It’s important for GPs to reassure their patients that telehealth is an ideal way to help assess conditions. In some cases, it may be necessary to have a face-to-face appointment.”
For further information, the COH have produced a number of telehealth guides to support clinicians and patients. https://coh.centre.uq.edu.au/quick-guides-telehealth