Last week this opinion piece appeared.
Telehealth—Improving access for rural, regional and remote communities
First published: 28 August 2020
https://doi.org/10.1111/ajr.12663
Over the past few years, the Alliance has been advocating for improvements to digital health capability and greater access to telehealth services for rural, regional and remote communities. The Alliance has been supportive of My Health Record, e‐prescribing, secure messaging and home monitoring, for their potential to enhance health care integration and bolster coordinated care for improved health outcomes of rural, regional and remote communities.1
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While the broader digital health transformation of health care may be moving relatively slowly, COVID‐19 has been the catalyst to rapidly change the Australian Government's policy position on telehealth services. This has been very welcome amongst rural health providers and consumers. The rolling out of the temporary Medical Benefits Schedule (MBS) telehealth items since March to GPs, medical practitioners, nurse practitioners, midwives and allied health providers has been vital to help reduce the risk of community transmission of COVID‐19 and provide protection for patients and health professionals alike.
Now is the time to capitalise on the Government's common‐sense approach to averting a health care crisis and embrace the use of digital technologies and telehealth options for a whole range of purposes, settings and demographics. The uptake of telehealth services in general practice between 1 April and 30 June 2020, during the height of the pandemic, was at 30.7% and even higher for mental health services offered by allied health providers and specialists, at 43.4% and 38.0%, respectively. For allied health and specialist providers of care other than mental health, the use of telehealth was lower at 3.8% and 23.7%, respectively. Notably, allied health and specialist providers of health services made greater use of videoconferencing telehealth than GPs, who only used this modality for 3.5% of services.2
There appears to be enthusiasm for the continuation of telehealth MBS items amongst the health care sector and consumers. A recent survey conducted by the Royal Australasian College of Physicians during the COVID‐19 pandemic reported that 87% of respondents supported retaining the new telehealth items beyond the current crisis. The survey also found that almost 70% of the sample of members stated that their patients were more likely to keep their telehealth appointments than their face‐to‐face appointments, which suggests that the convenience of not having to travel to appointments is highly attractive to consumers, regardless of place of residence.3
Previous research published in this journal has already demonstrated that using telehealth‐based models of care can have benefits for those residing in rural and remote communities, the health care provider and the system.4, 5 One study showed that telehealth can be successfully applied to the management of patients with a spinal fracture, which allowed the patient to be cared for in their local rural hospital and offered opportunities for allied health professionals to upskill and work to their full scope of practice, while also providing cost efficiencies for the health service.5 Another innovative application of telehealth was an integrated approach to oral health in rural aged care facilities with an oral health therapist screening residents using an intraoral camera probe that transmitted a live feed to a dentist in another health care facility.4 With so few dentists living in rural and remote Australia, there is real opportunity to scale up this sort of application of telehealth for other population groups such as Aboriginal and Torres Strait Islander people living in remote communities. In rural and remote education settings, speech pathology teletherapy services have been able to overcome limited connectivity issues by successfully using low‐bandwidth videoconferencing facilities.6 These examples demonstrate that telehealth can offer rural and remote communities a more flexible and convenient mode of access to health care, while also upskilling rural health generalists, parents and educators by linking them and their patients or clients to urban‐based specialists.
An issue that still needs to be addressed more fully is the quality of telehealth services, particularly when considering the use of telephone versus videoconferencing consultations. Certainly from the perspective of specialist physicians, videoconferencing is considered preferable for patient assessment and establishing patient rapport. It is better for communicating with geriatric patients and those with impaired hearing and those from a non‐English‐speaking background.3 However, the same survey found that many elderly patients found it difficult dealing with the technology required to use videoconferencing platforms and poor connectivity was also flagged as a problem for those living rurally. One of the recommendations from the report was that Government should consider additional funding for videoconferencing and other digital health technology for selected households.3 The Alliance would certainly support such measures, but there must also be resources put towards improving digital health literacy for both consumers and health care providers so that all Australians can be enabled to make optimal use of digital and telehealth services.
One final consideration in the move to greater access to telehealth services must be about ensuring that rural health private providers are offered protection from telehealth providers that offer no local services. The Australian Government's recent decision to reform the Medicare‐subsidised telehealth services is helpful. Under stage 7 of the telehealth reforms, the GP telehealth provider will be required to have an ongoing relationship with the patient receiving the care to enable continuous, high quality care. Specifically, the patient will have to have seen the same GP or practice in the last 12 months to be eligible to receive the Medicare rebate. Ultimately, without some safeguards, primary care practices, particularly those in rural and remote communities, may not remain viable, which short‐changes rural communities in the long term.7
Here is the link:
https://onlinelibrary.wiley.com/doi/full/10.1111/ajr.12663
A useful review of the present situation (other than a keenness for the #myHR) which reveals at the end a desire to restrict some access to services to save money and preserves some incomes presumably.
This article shows how this may be rather discriminatory.
Telehealth changes risk sexual and reproductive health delivery
Authored by Deborah Bateson
WHEN COVID-19 hit Australian shores, governments and health care workers scrambled to prepare a response to the looming crisis unfolding around the globe. Like many places, including Canada, France and the UK, the Australian response in the sexual and reproductive health sector included a rapid upscaling of telehealth services.
Enhanced telehealth accessibility, funded through the Medicare rebate system, allowed people to access healthcare in their own homes through the March–May 2020 lockdown. The switch to telehealth was in line with growing international evidence of how the pandemic response has dramatically altered health care delivery in high income countries, given the imperative to provide physically distanced health care where feasible.
However, this early win for the health of Australians has been short-lived with new restrictions making telehealth inaccessible for many and leaving the nation at risk of falling behind similar countries such as Canada and France and the UK.
The 20 July federal government changes to Medicare mean Family Planning NSW, like other similar services, can no longer offer telehealth to new clients or anyone not seen face-to-face by our doctors in the past year, which represents a great many of the patients who come to us for help.
“From July 20, telehealth GP providers will be required to have an existing and continuous relationship with a patient in order to provide telehealth services. This will ensure patients continue to receive quality, ongoing care from a GP who knows their medical history and needs. A relationship is defined as the patient having seen the same practitioner for a face-to-face service in the last 12 months, or having seen a doctor at the same practice for a face-to-face service during the same period.”
These cutbacks, while aimed at preventing rogue operators, also affect the most vulnerable patients. Global predictions of higher rates of unintended pregnancies, unsafe abortion, short interpregnancy intervals and untreated sexually transmissible infections (STIs) are all highlighted in our recent BMJ Sexual and Reproductive Health editorial.
Telehealth delivered health care to more than 1500 Family Planning NSW patients from 30 March to 20 July 2020, and accessing advice on contraception was the number one reason people used our telehealth service. We found telehealth greatly improved access to essential health care – particularly for people living in rural and remote areas, young people and those not connected with a regular GP. Assessments for long-acting reversible contraception and provision of contraceptive pill scripts, medical abortion and STI screening were all important health care services being delivered effectively by telehealth.
Telehealth is truly valuable for improving health and outcomes both in this pandemic environment and beyond, as we move to our “new normal” way of life. Telehealth delivers health care access to marginalised patients unable to attend in person because they live in a rural or remote area, have a disability, or live busy lives juggling work, young children and caring for elderly relatives.
It also opens access for young people who were the largest users of our telehealth service. In fact, from March to July 2020, 700 people aged 20–29 years used our telehealth service to access health care. We know this age group is particularly unlikely to have a regular doctor or may still be tied to a family GP with whom they prefer not to discuss sensitive sexual and reproductive health concerns.
The very nature of our specialised practice means we do not routinely provide continuity of care but rather see people when the need arises, with referral back to their GP for their ongoing care.
These telehealth restrictions mean many of our potential patients can no longer access our services nor those of other service providers, including GPs with specialised skills, as they do not fall within the current criteria. It is a sad reality that for the most vulnerable people in our society, these changes which can block access to telehealth will simply mean health care is not available.
Since the new restrictions rolled in, many of our patients can no longer access vital health care, including contraception, STI care, and medical abortion. So far, since 20 July, 48 people have been unable to access essential health care through our telehealth services due to the Medicare rebates changes.
The increasing chlamydia rates among young people, rising numbers of gonorrhoea diagnoses in women and men and the rise in new human immunodeficiency virus (HIV) infection diagnoses in the Aboriginal and Torres Strait Islander population mean there is no room for complacency in relation to STIs. Complications including infertility and chronic pain from untreated STIs can create ongoing cost burdens to individuals as well as governments.
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Having people turned away from essential health care such as contraception, STI checks and medical abortions in Australia in 2020 is a cause for alarm, and patients seeking these specialised services need their access to telehealth reinstated through an exemption to the federal government cutbacks.
Clinical Associate Professor Deborah Bateson is the Medical Director of Family Planning NSW.
More here:
Clearly there are some patient groups who may be disadvantaged with the planned benefits schedule changes and who really need special consideration in the COVIDTimes!
Maybe the ADHA might want to carefully review and then advise the Government on the best way forward to resolve the conflicting interests since they seem so have claimed telehealth as a Digital Health initiative on what I reckon are pretty flimsy grounds. The again, probably not, as they are really largely a clinical vacuum with a pretty small roster of clinical staff.
Certainly the work needs doing to minimise the unintended consequences and preserve balance!
While on the topic of telehealth I am wondering just how much care is going into measuring the impact on quality and safely of the care being received. I find it hard to believe there has not been at least a small negative impact. We really do need to know just what it is costing in these terms with such a rapid shift in the approach to so many consultations.
We are really still feeling our way with this transition I believe.
David.
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