While the first wave of the pandemic seems to be in the past, telehealth could well be the future, or at least a more widely adopted service that provides both clinicians and consumers with a convenient and effective alternative to face-to-face consultations.
Ask a GP if during the course of their career they have taken a phone call from a patient and provided clinical care, and the vast majority would resoundingly say ‘yes’. However, if you were to ask if that was a billed consultation, there would be an emphatic chorus of ‘no’.
And that, in a nutshell, has been the problem with telehealth. Doctors have been providing the service, albeit informally, for a long time without the financial incentive to do more with it.
However, this has changed with more than 290 telehealth (video consultation) or telephone (phone consultation) item numbers being listed on the MBS since the start of the COVID-19 pandemic.
Yet, will clinicians continue to use this service when physical distancing measures are rolled back? Will telehealth be an effective and secure alternative to face-to-face care delivery? And will general practice be economically viable if telehealth comprises a larger portion of billable hours?
Before the pandemic, the primary use of telehealth consultations was to bridge the distances between clinicians and their patients located in rural and remote areas. They constituted a small portion of doctors’ consultations. However, the reality, now, is that telehealth can be as effective for a patient one kilometre away as it is for one who is 1000km away.
And beyond the financial aspect, telehealth complicated the traditional face-to-face delivery and interrupted clinicians’ daily work flow, said Dr Nathan Pinskier, a Melbourne-based GP, director and co-owner of the Medi7 group of practices and former chair of the RACGP National Standing Committee for eHealth.
“If the model of care is based on people coming through the door every day and the waiting room being full, it is seen to be disruptive to slot a telehealth consultation [in-between face-to-face consultations] as there isn’t a model to support it.
“Unless you’ve actually created a whole model of care for telehealth, as has occurred in other parts of the world, it isn’t well suited to our system, which is predominately fee-for-service and face-to-face.”
Acceptance through necessity
The rapid integration of telehealth and transformation of the delivery of care was remarkable, according to Dr Pinskier, who spoke of the situation his group of practices went through.
“We’ve gone from a model that is predominately fee-for-service and MBS supported with full waiting rooms to basically telling patients, ‘where appropriate, we’ll give telehealth consultations, if the doctor is likely to be at risk of being exposed to COVID’.
“The net consequence of that is 40% of our consultations are being done by face-to-face and about 60% are being done by telehealth, of which 90% is over the telephone.”
Although the new MBS telehealth item numbers have the same values, or bulk-billed rebates, as face-to-face, without the ability to charge a gap, the financial viability of practices offering the service post-pandemic is in doubt. There are, of course, services which
will always require face-to-face consults but there is also many for which a telehealth consult would suffice.
Dr Pinskier said general practices had been reporting some reduced income, which could be attributed to telehealth, but there had also been a decline in face-to-face consults.
“There are some scenarios where doctors are not going to drive the same income. Surgical procedures, for example, are items that obviously can’t be recouped through telehealth and are potentially lost income.
“By and large, it’s relatively comparable for non-interventional procedures, but it’s hard to know what’s happening across the sector. We are getting reports of reduced average income of between 10% and 25%.”
With flu vaccinations being administered early and a milder flu season predicted, lower patient volume may continue, which may also cause GPs some financial woes, Dr Pinskier said.
Keeping it private
Alongside financial concerns, Dr Pinskier added that privacy of telehealth communication was also problematic.
“A lot of basic business rules and work we’ve been doing over the past decade have gone out the window, particularly around secure communications.
“Once the crisis comes to an end, it’s inevitable that some patients will grow concerned about possible breaches of privacy and questions will be raised about why doctors didn’t ‘lock it down?’, or the lack of a national protocol.”
Part of the privacy problem is the effectiveness of the technology being currently used and the times where convenience was prioritised over security, he said.
“If I don’t want a patient coming to my waiting room but I want to get information to them, that probably means sending an email.
“How is it that eight weeks ago the use of ordinary email was deemed to be totally inappropriate for health care
communications and a crisis comes along and today it is perfectly acceptable,” he said.
“Now we’ve let the genie out of the bottle, shall we put it back in or do we just change our thinking, design different rules and different tools? I think that’s the conversation we’re going to be having going forward.”
Limits of control
Loosening the controls over privacy may seem innocuous in the moment, but the consequences could be damaging to the patient and the clinician.
Yet, the pervasion of the internet into our lives has primed us to choose convenience and be apathetic to the cost and commodification of our privacy. Simply reference the tome-like terms and conditions of almost any tool or service found on the internet for evidence as to how your data is used.
One such tool that has been elevated as a result of COVID-19 has been Zoom, the convenient video conferencing service that offers free video chats to its users.
However, privacy concerns were raised about its lack of end-to-end encryption, providing user data to Facebook, and a tool that mined real-time data of attendees’ LinkedIn profiles, even if they chose to be anonymous, without disclosing this to users.
Although Zoom is discussed in some detail, it is merely an example because of its rapid growth and popularity and its problematic use for clinical consults
Prof Dali Kaafar, Executive Director and Chief Scientist at the Optus Macquarie University Cyber Security Hub, is a specialist in analysing and quantifying risks from an information theory perspective and has extensive experience researching privacy enhancing technologies.
“The software and tools we use today are tangled in a very diverse ecosystem. For example, when we connect with Zoom servers, there is information that will be extracted for so-called analytics functions for third-party trackers and servers.
“This is nothing new… most of the websites and servers that we use today include these sorts of analytics and third-party tracking mechanisms that leak information about us.”
He said in the case of Zoom, while the user information collected is primarily to improve and enhance the application’s performance, we are allowing personal information to be extracted as a trade-off and for the most part, end users a happy with this as they receive a better service.
Modelling the threat
For clinicians and practices interested in maintaining privacy, Prof Kaafar suggests conducting threat modelling.
“To understand the privacy risks, it is essential to assess whether something is a serious privacy issue or loss, or an impractical, unrealistic scenario,” he said. “In the case of a third-party accessing information, it depends on what is in the meta data and who has access to it.
“The threat model in this instance would be, ‘what is the information available to an entity about Patient A and
Doctor B?’ ‘Do we really know any more information about these two entities other than their IP address?’.
Prof Kaafar also urges clinicians not to underestimate the power of data mining and to be overcautious not to reveal information that could be aggregated, such as quasi-identifiers – – ages or postcodes are particularly problematic for privacy loss as they can be used for re-identification, according to Prof Kaafar.
Managing the change
With more clinicians and patients using telehealth, this could be the tipping point for wider acceptance of the services. However, this is contingent on the government maintaining the MBS item numbers beyond the pandemic. Dr Pinskier is confident it will.
“It’s inevitable that we will see an extension of telehealth item numbers in some shape or form,” he said. “It’s hard to envisage the government, consumers and providers allowing telehealth to be abolished and be happy to return to the way it was pre-COVID.
“The world has moved on and people who were reluctant or resistant to implementing telehealth, for whatever reason, have now come to accept it as just part of the fabric.”
Dr Pinskier said from his conversations with the MBS, the government will look to amend the current item numbers based on how the system is being used.
“They will probably implement some controls or restrictions because at the moment it’s relatively unrestricted. My guess is post-September or maybe next year before we will see any significant changes.
“There’ll be some linkage back to principal practices. I’m not sure we want to see an open access world where anyone can set up a telehealth service in the absence of a physical practice.
“We allowed virtual providers to set up and there’s no continuity of care as they tend to cherry pick the low-hanging value services such as repeat prescriptions and minor conditions and have taken these consultations from general practices but without the continuity of care.
“So, there will need to be some rejigging of the item numbers, their relative value and how they’re accessed with requirements that data be linked back to the regular general practice or the regular provider.”
Dr Pinskier believes the MBS is constrained by its history. It was developed in the early 1970s as Medibank then in the 1980s as Medicare. As doctors are all too acutely aware, the medical and financial landscape is totally different today from 40 years ago.
“It was a model that was fit-for-purpose for its time but the world has changed and we have moved into an era of chronic complex diseases. The average person over 65 takes something like five medicines,” he said.
“The MBS was designed as a transactional process. However, we are now looking at it from a longitudinal care process and we need to change it to fit the world in which we’re operating.
“So that’s going to require a reform of payments for certain services. How we get there is going to be challenging as none of the models so far have really been effective or acceptable within general practice.”
Modern model of care
If the MBS were more flexible, this could lead to a more appropriate model of care for the patient, the practice and the clinical context, said Dr Pinskier.
“Take my 94-year-old mother, for example,” he said. “Would she need to go every couple of weeks to see her GP if she could be managed appropriately over the phone? She could ring up her doctor and get her care over the phone rather than spend an hour getting to and from the surgery for a 10 or 15-minute consultation.
“Once we remove those shackles around the MBS, and have funding that fits that model, we’ll see a lot more of this. It could also allow practices to triage patients over the phone and if they don’t need to come in, they don’t come in and the practice gets paid for it.
“At the moment, the only way you get paid this type of care is for the patient to walk into your consulting room.”
As far as what the most appropriate model of care could be, Dr Pinskier envisages once that embraces telephone, video and face-to-face consultations, such as what has been embraced in other countries, such as the US.
“It’s almost impossible to believe that it’s not going to continue in Australia as the world has moved on and we found we can do it another way and use our time much more productively.”
The recent growth of telehealth in Australia is a prime example of a bottom-up intervention in healthcare that provided appropriate outcomes for clinicians and patients that needed it. Now it is up to those same clinicians to continue with it to ensure that broad use of telehealth is here to stay.
“I have to give government a lot of credit. They listened and delivered. We now need to understand how to use it more efficiently and more appropriately so that we get the right benefits in terms of health care delivery outcomes,” Dr Pinksier said.
The Department of Health was contacted for comment for this article. No response was received before publication.