18 July 2022
Is telehealth the great panacea for rural health?
Simon Judkins, Belinda Hibble & Stephen Gourley
Instead of a telehealth explosion, where “we will get back in touch with you”, we need to refocus on a rural workforce explosion, where we can have clinicians and patients actually within hand’s reach of each other
OUT of a crisis comes opportunity, and with the effects of the global COVID-19 pandemic marching on, opportunities to transform many aspects of our health care systems have flourished.
One of the areas that has gained much interest is the potential expansion of investment in telehealth in its various guises. We have seen utility in supporting primary care, managing outpatient clinics, mental health consultations, and increasing use in emergency department (ED) settings.
The stars have aligned for this innovation in health care. Telehealth manages the risk of exposure to a wildly contagious disease (for both staff and patients). It allows for reduced movement of people within the community – a further benefit during lockdowns.
Now that the restrictions have eased and the world is opening up, we are seeing the results of delayed care and increasing patient complexity putting further pressure on an already overloaded health care system. Telehealth has hidden the queues, keeping people in their homes rather than placing them within overcrowded EDs and wards.
Much of the news has been good news.
With the evolution of telehealth, patients can have a video consultation with their oncologist from home and attend a local pathology centre for blood tests. They look forward to more time to have questions answered, less travel-associated stress, lower costs and less fatigue. This example is one of many improvements in genuine patient-centred care.
In the ED and primary care sphere, we have seen the emergence of privately run telehealth companies, such as Nurse-on-call, My Emergency Doctor, Virtual ED, Instant Consult, Doctors on Demand, Health Now, GP2U and others, using both State and Federal funding sources. Initially these were set up to provide consultation for people seeking health care in the community who were unable to access a GP. They may have been seeking a second opinion or wanted to discuss their health concerns but were unable to access the care they wanted in a timely manner.
These services have now extended into the EDs themselves, with many health services who are struggling to recruit and retain staff on the ground resorting to “virtual ward rounds”, whereby an Australasian College for Emergency Medicine-qualified emergency physician provides in-reach to an ED via a video link from anywhere in Australia, New Zealand and overseas, enabling 24-hour cover.
They liaise with junior medical staff and nursing staff in the ED, doing “rounds” of the patients within the ED, and offering advice regarding investigations and disposition. Certainly, the feedback from Urgent Care Centres has been positive, but the “replacement” model in EDs is raising significant concerns.
While we haven’t yet seen any independent analysis of the impacts, the oft-quoted mantra is “wouldn’t you rather have someone on a screen as opposed to no one?”; that is, don’t let perfect get in the way of good.
But wouldn’t we all prefer to have senior support embedded within that health service, available to come in and assist when that very unwell patient arrives?
A new service to emerge is a Melbourne-based public “virtual ED”, which arose before the COVID-19 pandemic to manage ever-increasing demand in the northern suburbs corridor and has expanded as the pandemic has progressed.
This was initially designed to be a pre-triage concept for patients (often unwell children and their parents) to access a virtual telehealth consultation rather than waiting in a crowded waiting room. We are seeing similar models advancing in Western Australia and New South Wales.
Patients, health professionals and paramedics can access an emergency physician in the virtual ED, who, with dedicated resources and time to undertake the role, can consult and offer advice to either direct the patient to the right place (not necessarily the ED), back to their GP, or provide care within the aged care facility, with many other permutations.
But diversion of care has become commonplace, with patients being bounced throughout the health care system. Anecdotes abound regarding patients who have attended multiple telehealth consultations through a GP, outpatient clinics and a virtual ED, only to finally arrive in a physical ED with a complex undiagnosed issue due to the lack of definitive examination and care planning. For example, lack of knowledge regarding the available services in regional and rural services has led to patients being referred to the ED for care, but finding the requested service is not available in that hospital.
The virtual ED model has quickly spread across urban Melbourne, with many EDs now having dedicated rosters for emergency physicians to participate in these virtual ED models, and now that the infrastructure is in place, this model is being rolled out to regional and rural areas; another urban-designed model of care is being thrust upon resource-deplete regional and rural areas.
In an era where we see GP shortages in regional and rural areas, with the inability to get an appointment with a GP for 3 weeks or more, waiting times for outpatient services blowing out, overcrowded EDs, and ambulance ramping at record levels, it isn’t easy to imagine how the system would cope if all of these services did not exist.
Despite the challenges, they give concerned parents, unwell adults and residents in aged care facilities many choices to access care from their own homes. But is this the right care? Do we know what the impact has been?
The truth is that we don’t know.
Where is the value proposition? Where is the cost–benefit analysis? Where is the governance and reporting that should accompany such a significant investment of very scarce and increasingly stretched health care dollars?
Much more here:
https://insightplus.mja.com.au/2022/27/is-telehealth-really-the-great-panacea-for-rural-health/
There was also some coverage here on the perennial issue of funding:
Rural and remote patients left behind by telehealth cuts: RACGP
Wednesday, 20 July, 2022
The Royal Australian College of General Practitioners (RACGP) has once again urged the federal government to make Medicare rebates for longer telehealth phone consultations a permanent fixture of the nation’s telehealth scheme so that patients living outside of major cities can get the care they need when they need it.
It comes following reports of a study released by Phillips, which found that 40% of people living in rural and remote areas had internet speeds that were less than 28 kilobits per second. This makes conducting telehealth video consultations challenging, if not impossible, given that the minimum recommended speed for video calls is 600 kilobits per second. In addition, other people are not confident using the technology or find the cost of purchasing a smartphone or laptop prohibitive.
The latest Medicare Benefits Schedule, which came into effect on 1 July, has removed a patient rebate for GP phone appointments longer than 20 minutes, but kept patient rebates for video consults that are 20–40 minutes and longer (>40 minutes).* 2.5 million Australians are not using the internet due to issues including access and affordability. It’s estimated that 1 in 4 people in Australia are being “digitally excluded” and unable to properly take advantage of digital technology, according to the RACGP.
RACGP Vice President Dr Bruce Willett said that rural and remote patients were being left behind. “Longer phone consults are essential for patients in rural and remote communities,” he said.
“Put yourself in the shoes of a patient in a small town with multiple health conditions, such as asthma and diabetes, who has to drive a long way to see a GP face to face and isn’t comfortable using video technology platforms. For that patient, a longer phone consult is just what the doctor ordered, but unless the recent telehealth cuts are reversed, they are left out in the cold.
“Removing Medicare rebates for longer consults is not only particularly detrimental for patients in the bush but also older patients across Australia, Aboriginal and Torres Strait Islander people, and those with disability or limited mobility. This is troubling as these patient cohorts already have poorer health outcomes than the general population. We are effectively denying healthcare access to those who need it most.”
To support safe, high-quality care for all Australians, the RACGP “firmly believes” that phone consultations must be:
- available for all GP consultation lengths and types
- valued at the same level as face-to-face and video items
- linked to a patient’s usual GP, with
some exceptions for services provided by GPs with special interests upon
usual GP referral.
* Whilst a level C telephone item is available in some remote areas, it is only applicable to MMM 6-7 areas (91894) – so only the most remote locations.
Here is the link to the release:
I have to say it is good to see people asking have we got the models for delivering remote care right, are we using it with the right people and do we have the payment methods right? It is also an open question on how much corporate activity we should see in the sector.
There is clearly more to come in the space!
David.
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