15 minute read
Into the Tele-future
Telehealth has stormed into GPs lives providing convenience and headaches.
James Knox reports.
Telehealth may have started slowly but the combination of a pandemic and the introduction of a comprehensive set of MBS item numbers is making it a go-to service for GPs in Australia.
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-toface consultations.
Ask a GP if in the course of their career they have taken a phone call from a patient and provided clinical care, and the vast majority would resoundingly have said ‘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 or telephone 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?
Useful use case 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 faceto-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 inbetween face-to-face consults 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 feefor-service and face to face.”
Acceptance by 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 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 exposure to COVID’. “The net consequence of that is 40% of our consultations are being done face-to-face and about 60% are by telehealth, of which 90% is over the telephone.”
Money matters 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 are others well suited to telehealth. 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.
“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 10% to 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. 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 it be a Tele-future?
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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,” he said.
“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.
“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-toend 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. 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 perspective and has extensive experience researching privacy technologies.
“The software and tools we use today are tangled in a very diverse ecosystem. For example, when we connect with Zoom's 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, users are allowing personal information to be extracted as a trade-off for a free, convenient and effective service, which could be problematic for a clinician discussing confidential patient information.
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 there 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 quasiidentifiers – age or postcode are particularly problematic for privacy loss as they can be used for reidentification. 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.
“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 away these consultations from general practice 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 aware, the medical and financial landscape is totally different today from 40 years ago.
“It was a model that was fit-forpurpose 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.” model of care for the patient, the practice and the clinical context, he said: “Take my 94-year-old mother, for example. Would she need to go every couple of weeks to see her GP if she could be managed appropriately over the phone? She could 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 for this type of care is when the patient actually walks into your consulting room.
“It’s almost impossible to believe that telephone, video and face-toface consultations are 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 that provides appropriate outcomes for clinicians and patients who need 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.
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The challenges of telehealth
Dr Rosa Canalese, a GP and Senior Medical Advisor at Avant says the increasing use of telehealth has advantages but there are pitfalls.
MF: How do you think doctors are managing the rapid roll out of telehealth due to COVID-19?
RC: We’re receiving a lot of questions about telehealth because most doctors have had to adapt in a very short timeframe. It’s been a huge change to the way they practise. As a result, there has been little time to work through the problems or develop mitigation strategies.
MF: What are the major challenges for doctors?
RC: There are a number of challenges. Firstly, you can’t physically examine a patient so you have to devise strategies to get around that problem. Secondly, you need to manage the issuing and delivery of prescriptions, tests and referrals effectively. Finally, you have to ensure that your communication with patients isn’t compromised because, as we all know, communication is fundamental to effective consultations.
MF: What are specific communication issues arising with telehealth?
RC: In novel situations such as this, there is a risk that the quality of the conversation between the patient and doctor may be impacted. Both may have little experience of telehealth so the patient may not feel that they’re being communicated with effectively. They may not feel listened to or heard and, as a result, they may be more likely to be dissatisfied with the patient-doctor interaction and even complain.
While the risk may be mitigated by the fact that patients may recognise that COVID-19 is a unique situation and, therefore they may be more understanding, there are still risks that practitioners need to be aware of.
MF: So, what should doctors think about when communicating via telehealth?
RC: It is important to discuss the limitations of telehealth compared with a traditional face-to-face consultation with the patient up front.
We may need to think about how we are adapting our communication style for video conferencing or telephone. What do we need to do more of and what are we not able to do in these consultations? We need to consider how we compensate for the fact that we are not getting those non-verbal cues that we, as doctors, so often rely on. For example, if you’re on the phone, you may miss certain nuances in the tone of the conversation and you are not able to see patient’s facial expressions.
MF: So, not physically seeing a patient compounds the risks? How can communication help mitigate that risk?
RC: When you think about the core function of a consultation, one of our key responsibilities is to gather sufficient ‘data’ to work out what is wrong with a patient so we can either formulate a diagnosis and/ or a problem list. Then, we need to think about what we’re going to do about that problem list. The quality of the data that you collect is important because it informs the quality of that decision making. So, if you don’t collect sufficient data or you collect inaccurate data, it will affect both the quality and accuracy of the diagnosis and management.
how you need to obtain it because you can’t do a physical examination at that time. This may involve asking different questions, more exploratory questions or even ‘checking the understanding’ questions and the information patients are giving you.
MF: What strategies do you suggest doctors employ to communicate more effectively via telehealth?
RC: You need to ask the questions that we normally wouldn’t have to ask a patient because we’d be seeing it. For example, you may need to ask specific questions such as ‘Is your knee actually swollen?’, ‘Is you knee red?’ or ‘Is your knee hot?’. You may even want to ask the patient to send you a picture of their knee. When you do this, you need to ensure you are maintaining patient confidentiality and that you include a copy of the photo in the patient record.
MF: Will employing these kinds of strategies help doctors reduce their medico-legal risk? RC: Yes. This is because if you don’t get the data you need and ask those questions there is a medicolegal risk of doctors making an incorrect or inaccurate diagnosis. There is also a risk of doctors providing incorrect management of the problem because they are working from an incorrect or inaccurate problem list.
In the end, it is about thinking about what are the medico-legal risks and what strategies we can put in place to help mitigate those risks. You can never mitigate the risks to zero but you can lower them.
Most importantly, if you need to see the patient face-to-face to properly assess them, then, you need to set up a process to do this. This may involve asking them to come into your practice for a consultation, referring them to another practitioner or referring them to the hospital.
MF: What other steps do you suggest doctors take to mitigate the risks of telehealth?
RC: The reality, at present, is that doctors are under a lot of stress. And we know that when people are under stress and distress they are less likely to make clear decisions and even become chaotic in their thinking.
We are also aware that, at the moment, the vast majority of telehealth consultations are occurring via telephone despite the Department of Health’s preference for doctors to use video. So, I’d suggest that both practices and doctors explore moving across to video conferencing.
You should also avail yourself of the resources that are available such as the colleges, the PHNs, public health units who supply reliable and trustworthy information. There is a comprehensive Frequently Asked Questions and other resources on telehealth on the Avant website that focuses on the medico-legal risk.
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