(00:40) Dr Singleton and Dr Stoupas acknowledge that as GPs, they’ve had to band together and learn from each through the COVID-19 pandemic. Telehealth is an emerging discipline where this has happened and one of the unlikely upsides to the global pandemic.
Dr Stoupas comments on the actual geography of telehealth. ‘It’s critical that you actually ask where your client is and who they’re in this new scenario because you’re no longer in the same space.’
Dr Singleton wasn’t confident that this format would deliver the same quality care in the beginning, however she’s since been convinced and it has revolutionised consultancy. Dr Stoupas is a little unimpressed with the prescription process and new challenges GPs encounter on that front. Both acknowledge the importance of patient privacy, security and the necessity for a robust platform, and systems like Firefox Send encrypted to manage data.
(02:50) One of the previous stumblers to making telehealth a viable way to consult was the lack of MBS item numbers. The COVID-19 crisis has expedited their implementation, but Dr Stoupas is strongly advocating that the MBS item number project is well managed and done with longer-term objectives in mind. Dr Singleton notes that these MBS item numbers are currently only in place until 30 September, but is hopeful that they will remain as they are particularly important for chronically ill patients who make up about 50% of consultations.
Introduction of Dr Amandeep Hansra
(04:50) So, tell us about your background in telehealth.
Dr Hansra is a GP and has had an interest in telehealth for a long time now. In fact, she’s been working with telehealth for about 10 years. Her advocacy of the approach is based on the benefits she perceives for those in rural areas, or in need of help after hours. In general, the overall convenience of this form of consultancy was something she saw the upside of well before the emergence of COVID-19.
(5:50) Dr Singleton notes that doctors have had to hit the ground running with regard to responding to COVID-19 and telehealth. There have been suggestions that there could be some rorting of the system … Does Dr Hansra have any comment?
Dr Hansra has been involved in discussions with Medicare over MBS item numbers with regard to telehealth for a long period of time now, and one of the concerns was that GPs might claim for multiple phone consults without providing the quality of care that a face-to-face session would deliver, and as a result end up with a Medicare blowout. Dr Hansra suggests that time with a GP whether face-to-face or via a telehealth platform should basically be treated as consultation time and she believes that GPs will provide quality care regardless of the technology. Her concern is more to do with fully automated and 100% virtual providers who provide simple services like repeat scripts and referrals. Not only do the regular bricks and mortar GPs lose out on that traffic and revenue, but the patient ends up with fragmentation of their care and their records. Continuity of care is at the heart of the GP ideology and these services are a threat. She suggests that patients first check with their GP to see if they offer form of remote access and telehealth before taking up the service of a 100% virtual one.
(09:00) Dr Singleton shares the concerns regarding patient treatment fragmentation. Dr Stoupas steps in with his thoughts and asks about keeping telehealth MBS numbers going with clinic accreditation measures.
Dr Hansra acknowledges that once we get past COVID-19 situation and in order to support the implementation of telehealth MBS numbers, there will need to be a process put in place to identify restrictions that will allow the benefits of telehealth to be offered to patients without unintended consequences. Dr Hansra agrees that attaching an accreditation to a physical practice could be helpful in making that work. There has been discussion about limiting accreditation of telehealth to clinics that open their doors for more than four hours a day. And there had also been discussion around the requirement for a patient to have been a patient of the clinic and visited within the last 12 months. But that was passed on as some patients would not have seen a GP at all in the last 12 months and they didn’t want to be discriminatory. Having said all that, there will need to be a way to protect the continuity of care and the attachment of patients to their GPs and to avoid the ‘uberisation’ of general practice.
(11.30) Dr Stoupas feels that the ‘open four hours’ practice is not a strict enough measure. He also ponders the 12-month window for patient consultancy as a disadvantage for some patients and clinics.
Dr Hansra confirms and expands on the rationale for abandoning the 12-month measure. It could have affected many practitioners who, for instance, might have been returning from maternity leave or moving to a new practice. So, linking the 12-month interaction between patient and GP or practice was not the right way to create the threshold for access to telehealth. Dr Hansra is confident that there are lots of creative ways to put restrictions in place, but the trouble in this situation was that they had to come up with the plans so quickly that all of the potential fallout couldn’t be properly considered. There are so many sorts of unique requirements, for example, those from Aboriginal and Torres Strait Islander communities, rural centres, refugees, compared to the large scale of metropolitan bulk-billing centres, to more boutique practices. It’s a different experience for all and the impact of MBS item numbers regarding telehealth needs to be properly considered. A full consultation process is required to understand the levers.
(13:32) Dr Singleton offers her congratulations to Dr Hansra for her advocacy in this space and the ultimate benefit to patients. She is interested in Dr Hansra’s perspective on some of the more vulnerable cohorts, particularly the elderly and their uptake of telehealth.
Dr Hansra believes that we tend to underestimate patients’ ability to adopt to new technology and to change in general. She feels that our generalisations and assumptions around the elderly not being able to manage an iPad or to interact via technology are largely incorrect. Patients are able to manage it and are grateful that they can avoid leaving home in order to keep themselves safer from exposure to the risks of COVID-19 or the flu, etc. They’re quite used to using video platforms with their family and there’s not as much resistance to this sort of change as you might think.
(15:05) Dr Stoupas asks about risk of relying on telehealth. Is it safe?
Dr Hansra acknowledges the worry that some GPs might have about relying on video to make a diagnosis. If they can’t touch a patient, they worry that they could miss something. But she feels that GPs need to give credence to their experience and the history of a patient. They are good at interpreting that valuable information as a benchmark. It’s also critical to rely on what’s in scope and to make sure that if something falls outside of that and does requires a physical examination, that is done. Reverting to face-to-face consultation is going to be required if there are any concerns. So, if you stay within scope, follow evidence-based practice, and always revert back to a face-to-face consultation, you can practice telehealth very safely. Dr Hansra also thinks that the video platforms are best for telehealth. Just eyeballing a patient can make all the difference in knowing who’s really sick and who’s going to be okay.
(16:35) Dr Singleton also acknowledges the importance of seeing patients on video. In her experience with patients whose first language isn’t English, video has made a huge difference. Her clinic has recently adopted the Healthdirect platform, and this is one that Dr Hansra has been heavily involved in.
Dr Hansra has been using Healthdirect Video Call – a free telehealth platform available for some health services and GPs through their Primary Health Network (PHN).
She outlines that it meets the Australian privacy principles and is a platform that’s been endorsed by the Australian Government. It is also HIPAA (Health Insurance Portability and Accountability Act USA) compliant, which should boost reassurance around privacy and security issues. Dr Hansra confirms that there is no requirement for Medicare telehealth item numbers to be tied to a particular platform, but using one that suits a GPs workflow in general practice, as well as meeting privacy and security standards, is really important.
(18:27) Dr Singleton acknowledges that many GPs starting out in telehealth were just making do and using services like Zoom and Skype. Now they all understand the significant security concerns around some of those platforms.
Dr Hansa concurs that often you might not know where the data is hosted on some of those platforms, so to be confident using an Australian-based platform does give that reassurance.
(18:57) Dr Stoupas asks about collecting data. Is there any way to improve our case to keep telehealth item numbers going by sifting through the recent data?
Dr Hansra loves the idea of research. As a result of the soft uptake and utilisation of telehealth in Australia before coronavirus, there isn’t an awful lot of solid information to get a good picture of what was happening or what could happen. But because of the pandemic, we have now done over 5.6 million telehealth consultations in just the month of April. Digging into that information would help us to understand who’s using it, how are they using it and what are the outcomes. We’d understand what the patients think, what the GPs think, what we could be doing better and some of the outcomes that we weren’t expecting. She concludes that if we want to make people feel comfortable with telehealth, we need to understand how it worked through this period and encourages anyone who has an interest in research to get busy.
(20:49) Dr Singleton enthusiastically agrees that demonstrating the benefits of telehealth through the lens of the Coronavirus lockdown would be a wonderful outcome, and is very grateful for the Dr Hansra’s insights and experience.
Dr Hansra hopes they can reconvene at point, after September to see how telehealth looks then with a view to celebrating its success.