This appeared last week.
Phone consults are risky: My 'Spidey sense' saved a serious misdiagnosis
Dr Ro Goel is a GP and cosmetic physician, Cairns, Qld.
6th September 2021
As the COVID-19 pandemic has spread across the country telehealth consultations have increased too. And with them the inability to practise medicine as we’ve all been taught from medical school.
Telehealth has severely limited our ability to perform proper history taking, physical examination, bedside testing and the chance to use our ‘Spidey sense’ as I call it.
This Spidey sense is the gut feel that GPs get on seeing a patient in-person that intuitively guides us on whether they are genuinely sick or not, despite what they may be saying.
The classical cases are undiagnosed depression and cancer, where we can see the patient lacks emotion or is pale and cachectic even though they’re saying, “I’m fine doc”.
Back in 2012, I worked in the UK for the GP out-of-hours service that involved a lot of telephone triage and managing patients remotely. One night I was the only GP cover for three million people in London, so I was told.
We had the ability to arrange face-to-face consultations and perform home visits when needed, to ensure high-quality care and that we didn't miss any serious diagnoses.
But last month, the heightened clinical risk that comes with phone consults came flooding back when Cairns, where I now work, was plunged into a three day mini-lockdown following an isolated case of the Delta variant.
The bulk-billing clinic where I was working at moved most consults to telehealth and I was fully booked all day.
My last telehealth appointment was scheduled for 5pm, however, I was running a little early so I called the patient at 16.15 pm.
He was a 37-year-old man that I didn’t know, on the phone he stated very vaguely that he had sore shoulders and upper back pain.
He worked in a physical job lifting heavy items all day. My initial differential diagnosis was musculoskeletal pain due to his age and job.
I questioned him further and he said he’d had upper chest pain that woke him at 3am, which he thought was indigestion. So another differential that occurred to me was reflux.
However, something in me was not satisfied so I asked him if he could come in and see me face-to-face to which he agreed.
**** Lots of details omitted. ****
This case shows the level of risk we manage as GPs every day that is only being compounded by COVID-19, forcing us to make clinical decisions without the foundation of adequate history taking and physical examination.
Whilst we’re nowhere near the US in practising defensive medicine, these cases highlight the fact that there are serious pathologies out there in the community that are now presenting to us through riskier and unfamiliar pathways.
Last year an Avant survey of 1300 GPs revealed that 5% had had a telehealth-related complaint, however the survey did not clarify if telehealth consults result in more missed or delayed diagnoses of serious or potentially life-threatening conditions such as the above case.
It's uncertain what the AHPRA ramifications would be if a GP were to miss a serious condition such as MI or meningitis following a phone consult.
But one thing’s for sure, with COVID-19 rampaging through Australia, GPs will be facing more and more of these difficult and risky diagnostic challenges for sometime to come.
The full article is here:
This sobering tale makes one wonder what issues are flying under the radar.
There is also concern in the US.
Researchers say 'essential questions remain' about telehealth's diagnostic viability
The Society to Improve Diagnosis in Medicine found that although "telediagnosis" has potential, there's still a lot to learn about how it can work most effectively.
By Kat Jercich
September 10, 2021 09:22 AM
Researchers from the Society to Improve Diagnosis in Medicine released an issue brief this week aimed at exploring the reach, effectiveness, adoption, implementation and future prospects of telehealth.
By combining literature reviews and interviews with a wide variety of stakeholders, the team sought to identify the most pressing research questions on how to maximize telediagnosis opportunities – while avoiding possible problem areas.
"We found that telediagnosis has potential, although there is still much to learn about how virtual diagnosis can be done most effectively," said Suz Schrandt, senior patient engagement advisor at SIDM and principal investigator on the project, in a statement.
"We found that many patients like the convenience of telemedicine, but we also need more research into who is being left behind in the process, such as small practices or people without access to high-speed Internet," Schrandt continued.
Lots more here:
This is relevant on the same theme:
How physicians can protect themselves from litigation risk from virtual care
Medical Economics Journal, Medical Economics September 2021, Volume 98, Issue 9
With virtual care on the rise, physicians need to understand the risks when caring for patients.
Telemedicine and telehealth services were growing before the COVID-19 pandemic, and demand has soared since the March 2020 shutdown as patients and providers alike recognized the efficiencies and convenience of delivering care remotely. However, along with the surge in demand for virtual care comes higher risk of malpractice claims for health care professionals.
Misdiagnosis risk
One of the biggest risks in the act of practicing medicine virtually involves the challenges of virtual examinations: reviewing diagnostics, communicating with the patient and loss of contextual clues, among other factors.
Two-thirds of telemedicine-related claims received between 2014 to 2018 were related to diagnosis, according to CRICO, the risk management arm of the Harvard Medical Institutions.
Physicians conducting a telemedicine appointment must rely on a patient’s description and interpretation of their symptoms to try to make a diagnosis without the benefit of testing and physical examination, as at an in-person clinical visit. That could more easily lead to misdiagnosis, missed symptoms or physical clues, prescription of the wrong medication and the potential consequence of prescribing medication across state lines without conducting an in-person examination (a criminal offense in some states).
Lots more here:
There are lots of differences with virtual vs in-person consultation and we have all rather rushed into mass adoption without some of the usual care and control.
Time to step back, get proper
evidence and regroup I reckon. Of especial interest to me is the difference in quality and safety between telephone and video modes of contact.
David.
16 comments:
The there's eprescribing.
Health issued a Request for Information on 10-Sep-2021:
"Operating And Funding Models For The Electronic Prescribing Ecosystem"
Seems a bit backwards to me - build and implement a solution then work out the operating and funding requirements. i.e. solution first, them analyse the problem.
The RFI says:
"Significant improvements in the end-to-end Electronic Prescribing Ecosystem (EPE) have been achieved since 2012, with approximately 91% of dispensed scripts now digitally supported. As electronic prescription popularity continues to grow, there is an opportunity to:
• improve the customer experience for prescribers, patients and dispensers;
• optimise the EPE to support further scale;
• support further innovation; and
• ensure the effectiveness and sustainability of the operating and funding model."
Then the first part of the objective says:
"The Department intends to introduce a new operating and funding model to commence from 1 July 2022, to achieve five key improvements:
A. Customer (prescriber, patient, and dispenser) experience and innovation
• Customer choice will remain a core principle for the future operating model.
• Support customer choice by creating opportunities to design new and improved customer experiences, and foster service delivery innovation across the ecosystem (including in key components, e.g. dispensing systems and patient mobile applications).
• The Department is seeking to identify specific opportunities to improve customer experience and service delivery, as well as the enablers required to support these.
B. Digital health best practice
• Provide a model for technical service delivery that is aligned to the National Digital Health Strategy and facilitates interoperability (e.g. exchange of data).
• The National Digital Health Strategy outlines the foundational principles for digital service delivery, including the importance of availability and access to prescriptions and medicines information, interoperability, and improvements in data quality.
• The Department is seeking to explore potential synergies/opportunities with other digital health reforms such as diagnostic imaging and pathology eRequest/eReferrals."
The Department wants the advice to align with the "National Digital Health Strategy".
You know, the one that is about to be revamped.
And the MyHR is undergoing change primarily to introduce some degree of interoperability, maybe, we don't know. And they are trying to reframe both MyHR and EPE into ecosystems.
Healthcare is highly complex. A bunch of un-coordinated technology (in spite of what they say, it's all un-coordinated at the healthcare provider/patient level) is likely to make things less efficient and effective.
It reeks of the 'Department' desperately scrambling to find 'cracks' (chasms, crevasses) which it can enter (occupy, inhabit) in an attempt to become (appear, look, seem) 'relevant'.
A good analogy is a huge concrete wall, full of fault lines and cracks, and riddled with concrete cancer. Scape out the cancer, plug the holes, fill the gaps, and hope like hell the mighty edifice doesn't collapse like the 'Twin Towers'!
throwing mud at a wall to see what sticks?
Meanwhile behind the facade of the comic bookstore that is Health direct, all new was to waste time and money continue unnoticed
Sept 16 17:24 - nuggets like this?
Healthdirect Australia, the country's national public health information service, has announced a funding offer for online booking service providers to set up online booking systems at vaccine clinics and integrate them with the government's official vaccine clinic search and booking portal, Vaccine Clinic Finder.
Available in 16 languages, the said portal is the only system in the country that shows vaccine appointments across clinics registered with the National COVID-19 Vaccine Taskforce.
WHAT IT'S ABOUT
The offer tasks booking providers to build an API according to the specifications of the federal agency to enable the integration of vaccination service providers with the Vaccine Clinic Finder.
They will create a contextualised booking URL to the Healthdirect national infrastructure, which will then provide users with in-context appointment booking details, such as vaccine brand.
The industry-wide offer can be tapped by eligible online booking service providers who have an existing product currently used by at least 10 approved COVID-19 vaccine service providers.
Moreover, the government offer requires the software vendors to onboard vaccination clinics to their booking system and ensure available appointments are made within the system. Eligible clinics include Aboriginal Community Controlled health services, pharmacies and GP clinics approved by the Department of Health to provide COVID-19 vaccinations.
Healthdirect is accepting applications for the offer until 20 September.
WHY IT MATTERS
In a statement, Healthdirect said having more clinics integrated with the Vaccine Clinic Finder will make it easier for Australians to find their preferred vaccination clinic and book an appointment. Presently, "less than half" of government-approved COVID-19 vaccine clinics have an online booking system connected to the search portal; a number of vaccine clinics only allows telephone bookings.
Their integration thus will reduce the need for Australians to telephone clinics, search multiple booking platforms or present themselves at clinics without prior booking. Moreover, online bookings can help alleviate the administrative burden on the providers' end.
Greek mythology to the fore; MEDUSA methinks.
wonder if it will be any better than this:
Frustrated with Australia’s vaccine booking systems, Ken built his own
https://www.innovationaus.com/frustrated-with-australias-vaccine-booking-systems-ken-built-his-own/
It will certainly cost more and tale longer to implement. Probably about six months after the vaccine rate has hit 95%
The government is doing a lot of leading from the back these days.
@9:27AM Surely you know they are not building it for this pandemic. They are getting ready for the next pandemic. That makes sense.
@11:05AM Surely you know that it is being built only for the current pandemic?
"The industry-wide offer can be tapped by eligible online booking service providers who have an existing product currently used by at least 10 approved COVID-19 vaccine service providers."
There is no hint that they are after a generic booking service for any and all vaccines.
As always, the focus was on self-promotion and getting appointed to boards than leading. This should have been archived long ago. What is the reactive approach? Bring across her handmaidens from ADHA so you can sit around chatting and looking busy. ADHA, I guess, wins in this, sadly the Australian people and health workers lose.
We need proper people in charge of these organisations not weak, and be able ones
Look a lot like Healthdirect leadership dropped the ball and is panicking in an attempt to save butt.
7:52 AM, you only need to look at the Healthdirect leadership page on their website to see why. Federal Government health-related entities are built on some strange principles.
As a previous comment stated - ADHA wins with the migration of some to Healthdirect (absolutely), consumers and providers don't.
ADHA Staffer, not sure anyone wins really, ADHA can ill afford to lose any depth of knowledge. From those being put into not insignificant roles we as a nation are heading for a.... What's the word for it?
One of the underlying challenges government entities face with the IT aspect is that:
People enter Government IT for a short period, gain many paid for certs, build a resume experience record and quickly move on.
Those who stay too long either become jaded or process bound blunt enthusiasm and dampen any idea of innovation or drive.
That leaves a real lack of technical leadership. Those roles then tended to be filled by government people who, on the most part, enter government life to pursue policy or administrative duties.
Love it or loath it, NEHTA came the closest because it was an attribution away from the government, sadly government interfered, and NEHTA got polluted with heroes and other unsavoury types
What good is talent if you don't have the skill to use it?
With there not really being any carrots or sticks for standards and no really policy development around digital health, do we really need ADHA, CHf, health direct, Digiatl Health CRC, and all those many many other fifdoms.gov.au? Seems procurement teams do fine on there own.
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