HOW COVID-19 IS FAST TRACKING DIGITALISATION IN PRIMARY HEALTH CARE

FELLOWS HAVE GIVEN EXCEPTIONAL CONTRIBUTION TO THE PROJECT MANAGEMENT PROFESSION. HEAR FROM ONE HERE EACH QUARTER.

Let me first cover some background on health care in Australia especially the workforce and funding. It is important to understand the base line to measure if there really is a paradigm shift or just evolution. How the workforce and funding are organised in Australia makes our healthcare “system” more than complicated; it is complex by having several powers with different objectives influencing its direction with uncertain outcomes.

As a relatively young country, we are still encumbered by the influence of the development of the colonies starting in different locations; think of the rail gauge debacle. Governments are reluctant to change health, education or welfare systems because these are three of the key issues at election time.

HEALTH CARE FUNDING IN AUSTRALIA

Australian States fund public hospitals and a large part of specialist services. Private Hospitals are funded by private health insurance. Primary care, in the form of General Practitioners (GPs), Physiotherapists and the other 14 disciplines of Allied Health Practitioners (AHPs) are funded mainly by the Commonwealth Government.

All of these health care providers also receive funding from the community when there is a Gap payment. How the funding is calculated and paid provides incentives for the health care providers to focus on certain types and quantity of services. Siloed government and governance responsibilities also interfere with desired changes and the current Fee for Service payment system for GPs is entrenched in small businesses and politically unpopular to meddle with.

Activity Based Accounting in hospitals incentivises public hospitals to seek services rather than pass the service to Primary care where the patient may be more efficiently cared for. Laying over this the multiyear training of AHPs, GPs and Specialists in universities, gives us an inertia to overcome to implement change in the workforce (in addition to the normal reluctance we have as humans for change).

Then the professional clinical bodies all act in what they believe are the best interests of their members. For example, the Royal College of General Practitioners (RACGP), the Royal College of Physicians (RACP), the Australian Medical Association (AMA), the Australian Healthcare & Hospital Association (AHHA) and the Colleges of Surgeons, Radiologists and so on; two of the major focuses of these Colleges are post graduate training and standards of care. All these bureaucracies make changes more difficult to get implemented.

Now to some numbers. The Australian Bureau of Statistics (ABS) has forecast the Australian population to grow by almost 18% from 25.4 million in 2019 to 29.9 million in 2030 (see image below); with a higher proportion in capital cities. Of particular interest to us here is that the population group aged 65 years and older, who have a higher demand for ongoing care because of a higher rate of chronic disease in this age bracket, is forecast to grow from 4 million to 5.4 million people – 35%.

(Source: Australian Bureau of Statistics, Population Projections, Australia 2017)

On top of this, people with chronic diseases make more visits to GPs. The current Australia wide average is 4.5 visits per person per year and is forecast to grow to 6 visits per person per year, driven mainly by chronic diseases in older people. Then, if supply and demand were in equilibrium in 2019, Deloitte Access Economics suggest there will be a shortfall of just over 9,000 Full Time Equivalent GPs by 2030 based on the growth in population and increased visits to GPs.

Obviously, something has to give. Demand exceeding supply over the next decade is a given. Remember also that GP practices are small to medium sized private businesses and to some extent react to the market economy. In many population centres, GPs are not taking new patients. This reluctance to add patients is significantly influenced by the patient list they have which is growing older and seeking more visits.

Can price alone influence changes by an increase in price (the gap payment) reducing demand or reallocating resources to increase supply? Or is there a way of increasing the productivity of General Practice by optimising the way services are delivered other than seeing more patients a day?

The Commonwealth Government recognised this resource shortfall over a decade ago and provided funding for GPs to purchase computer systems in the belief that digitisation would improve patient throughput. So, by 2020 we find that between 90% and 95% of GP practices are computerised. States have also been digitising hospitals with electronic medical records (EMRs). Although secure data transfer protocols are available, most of this digitisation does not share comprehensive patient information to facilitate the proper transfer of care from acute care to primary care and vice versa and ongoing management of the patient in the new setting.

ENTER COVID-19

With the pandemic came restricted movements except for specific nominated reasons to move out of one’s home. So, we saw people reluctant to visit GPs and Hospital Emergency Departments and chronic conditions were starting to worsen. The Commonwealth Government responded quickly by funding “telehealth” consultation through Medicare for $2.4 billion – something they have been reluctant to do before. These consultations could be by phone or video and have been readily taken up by clinicians and patients. In addition, according to the Government tenders list, from March through June of 2020 there were about $300 million in tenders awarded to clinical application developers with a COVID-19 tag.

This supports the ongoing development and implementation of “digital health” applications which support the delivery of care remotely. For example, research has found that many people will fill out a form which assesses their need for stress and anxiety treatment. So, these non-acute mental health services can now be scheduled as they become apparent, where previously they went undetected.

(Source: Deepak Biswal, Founder and CEO, CareMonitor)

The ability for different applications to work together (grouped under the term “interoperability”) is also becoming essential for good team care arrangements. An example are ePrescriptions, which are being implemented across Australia where a QR coded token of a prescription is sent to a patient’s smart phone for the medicine. The patient takes that to the pharmacy to have the medicine dispensed or the GP sends it to the patient’s pharmacy and the pharmacy delivers the medicine – and the patient never leaves home.

GPs can now remotely collect clinical metrics entered into a patient’s smart phone via Bluetooth or manually. These clinical metrics are seen by the patient and transferred to the patient’s medical record in the GPs clinical system. The GP can see their patients’ details (shown in rows) and the recorded critical metrics (shown in columns) so GPs are able to monitor their patients’ progress using a traffic light system. The GP can also select a patient and see the trend in a particular clinical metric.

Patients can contact their GP’s clinic from home and seek advice from a Practice Nurse who in many cases can solve the issue allowing the GP to work on more intense cases. These patient profiles can also be shared, with the patient’s consent, with others in the care team outside of the GP’s clinic. What was taking years to change has happened in 3 to 4 months – that is a paradigm shift.

Author: Paul Campbell FAIPM CPPD joined AIPM in 2005, was the NSW President from 2007-2012 and for the last six years has been a PMAA judge. For several decades, Paul has worked in healthcare as a Project Director in the USA, Malaysia, Dubai and Australia with side excursions to Myanmar, Saudi Arabia and Hong Kong. Paul has consulted with governments, sterile product manufacturers, acute care and primary care. Over the last 10 years he has focused on digital health, especially remote care technology.