Technology in General Practice: Mobilising healthcare
The possibilities presented by mobile health are exciting, but care must be taken when implementing it in general practice.
The convenience and affordability of mobile devices, including smartphones, tablets and wearable monitoring devices, has ensured their ubiquity in Australian society. According to Deloitte’s ‘Mobile Consumer Survey 2015’, 79% of all Australians own a smartphone, while six out of 10 Australian mobile consumers own multiple mobile devices.1
The pervasive nature of mobile technologies has had a revolutionary impact on the way people live their lives, changing the structure and delivery of a variety of services from food and consumer goods through to airlines and banking.
According to Dr Nathan Pinskier, GP and Chair of the RACGP Expert Committee – eHealth and Practice Systems (REC–eHPS), mobile technologies may also present innovative possibilities for the healthcare sector in the form of ‘mobile health’, or mHealth.
‘Doctors can take a laptop or tablet or anything that’s wireless to the patient,’ he told Good Practice. ‘You can have a consultation in a different setting. You can potentially even have it in a different room from the patient.’
Looking further into the future, mHealth technologies such as wearable monitoring devices could transform the way GPs manage patients with chronic disease.
‘As the technology matures and we hopefully see the evolution of the Health Care Home, the potential for general practice to be able to collate data remotely – monitor someone’s glucose, or weight, or congested cardio-failure for someone with cardiovascular disease – means GPs may become remote coordinators,’ Dr Pinskier said.
‘Technology may allow us to do things through mHealth in ways that we can’t do them today.’
Despite such possibilities, general practice is yet to embrace mobile devices with the same enthusiasm shown by patients.
‘Outside of healthcare, mobile devices are used widely. Community expectations are [geared towards] the use of mobile devices,’ Jan Chaffey, chief executive officer of the Camp Hill Healthcare general practice in Queensland, told Good Practice.
‘We have been slower to adopt this in healthcare, mainly because of problems around privacy, confidentiality and patient safety.’
Despite his enthusiasm for the possibilities of mHealth, Dr Pinskier agrees that it is important for the healthcare sector to proceed cautiously.
‘People rush to use the technology because it’s there and it’s cool and easy, but the consequences and ramifications may not always be immediately obvious,’ he said.
‘Anecdotally, we know that clinicians are using their phones and portable tablets for all sorts of purposes, but it’s not exactly clear how they are safe-guarding the information contained on those devices.’
This situation highlights a major medico-legal issue surrounding use of mobile devices in general practice: while these technologies may be fast and convenient, the information they transmit is largely unsecure. Chaffey used email communications as an example.
‘Patients expect to be able to communicate on email, but they need to be made very aware that normal, unencrypted email is not secure and people outside of the intended recipient might be able to access it,’ she said.
General practices must abide by the Federal Government’s Australian Privacy Principles relating to the handling of sensitive medical information to protect patient confidentiality. There are serious consequences for breaches of these principles, ranging from fines to legal action against the practitioner or clinic. This means that conducting doctor–patient communications on mobile devices can potentially be dangerous for both parties.
‘If you’re not following the guidelines and rules around [patient information], there could be consequences down the track,’ Chaffey said.
According to Dr Pinskier, GPs who use personal mobile devices during patient care may also find themselves ensnared in practical issues related to systems and record-keeping.
‘A good example would be photography,’ he said. ‘Everyone uses their phones for photographs, hardly anyone walks around with a camera these days.
‘That’s fine in the normal environment, but in a healthcare setting you might have a patient who has a lesion or a skin condition. Taking a photo is a great idea.
‘The problem is, you’re recording it on your own device. How do you transfer it across to the patient records? How do you ensure confidentiality and privacy of that information, and that it’s not identifiable on your phone?
‘Your phone now becomes part of the record system, unless you can move that information across.’
Dr Pinskier also described how use of personal mobile devices in general practice can cause issues in terms of doctor–patient boundaries.
‘It could be sending an SMS [short message service] to patients, which becomes an issue itself,’ he said. ‘It raises a whole new challenge around, “If I send an SMS to patients using my own phone, I’ve exposed my own phone number and compromised my own privacy. I’ve also created the expectation that I’m online 24/7”.
‘Your work–life balance gets affected.’
Remote monitoring by way of wearable devices can present a similar problem.
‘There’s talk about patient devices that can feed information to practitioners for ongoing monitoring. It’s happening in some sectors and we’ve discussed it with our practitioners,’ Chaffey said. ‘The issue for them is the timeliness of response.
‘So if a patient is constantly monitoring blood sugars, blood pressure or whatever else, and they are feeding information through to the doctor, what process is in place if there is an urgent or a semi-urgent medical situation that comes in at 10 o’clock at night? The safety factor involved with that is an issue.
‘These are all things which will have to be considered and monitored very carefully in the future.’
Timeliness of response, maintaining doctor–patient boundaries and compliance with Australian Privacy Principles are all good reasons for the cautious uptake of mHealth in the healthcare sector. Nevertheless, things are slowly advancing.
‘I have noticed that the medico-legal workshops I’ve attended in the last 12 months are moving from, “No, don’t do it”, to, “Yes, you can do it, but you need to be careful about how you do it, and always with patient consent”,’ Chaffey said.
Before a practice can even begin to grapple with issues of privacy of patient information, however, the mHealth systems themselves must be implemented. And before this can take place, the practice has to consider cost.
‘Apart from the safety and security issues, you need a business case,’ Chaffey said. ‘The majority of general practices in Australia are private businesses, so you’ve got to be very mindful that you have a business case around how [the mHealth system] is going to be funded.’
Part of this business case should address issues of data backup and continuity.
‘Once you’ve started using [the mHealth system], how do you ensure you’ve got adequate resourcing for the devices?’ Dr Pinskier said. ‘If it fails, what’s your plan for business continuity?
‘It’s easy to do things on a trial basis, but once you embed [the system] it may require additional support and resourcing.’
Chaffey also stressed the importance of ensuring new processes provide a genuine benefit before putting them into action.
‘Anything you implement needs to fit into workflow,’ she said. ‘You can’t impose extra things on GPs that will take a lot of time.
‘It’s important to work out how you fit new systems into the workflow, how [staff members are] upskilled to make sure that it doesn’t take extra time and, of course, it’s got to be of benefit to staff and patients.’
Once these aspects have been considered and implementation has been given the go-ahead, the practice administration team will be central to the process.
‘The administration team members are really the implementers,’ Chaffey said. ‘[We run an] implementation trial and train staff, [which is] an absolutely essential part of any changes within a practice.
‘You’ve got to train everybody and put a lot of effort into that. I think that’s where we miss out a lot in healthcare in Australia – we don’t train people well enough with the systems they have to use within their practices.’
When the mHealth systems and infrastructure are in place, another essential step is to have a clear and official policy around the use of mobile devices and compliance with privacy requirements. This serves to clarify the issues and procedures for patients and practice staff members.
Chaffey’s own practice provides patients with materials on the subject.
As an example of how her practice system follows privacy guidelines, Chaffey described its use of SMS alerts for patients.
‘We SMS patients for appointment reminders,’ she said. ‘We also SMS for preventive health reminders, but we’ve worded them as such that there’s absolutely no clinical information in them.
‘In both of those scenarios, it’s always done with consent from the patient.’
The RACGP’s 2015 ‘Use of technology’ survey investigated how its members use mobile technology in their practice in order to help GPs navigate the growing terrain of mHealth.
The results of the survey informed the development of the RACGP’s new resource, mHealth in general practice: A toolkit for the effective and secure use of mobile technology (the toolkit), which was released at GP16.
Chaffey, who was part of the project team behind the toolkit, believes the guidance it provides will help to make implementation of mHealth devices a more manageable process.
‘It’s a very comprehensive resource that very carefully works through considering implementing mobile devices. It gives you a lot of explanation around it,’ Chaffey said. ‘It goes through some planning stages, trials, how you deliver it, how you review what you’ve done, and a step-by-step process.’
Given the constantly-evolving nature of mHealth, the RACGP is committed to updating the toolkit now and into the future.
‘[mHealth] is an additional resource and an additional tool and, like everything, its benefits become clear over time,’ Dr Pinskier said.
Dr Pinskier believes that while it is important to engage with the developments presented by mHealth and determine how to best use them, these devices should ultimately be considered an extension of traditional general practice, rather than a replacement.
‘We can access information and we can make that information readily available in all sorts of formats and locations that can be really convenient and beneficial,’ he said. ‘But we shouldn’t confuse the access to information with the clinical skills of a qualified medical practitioner.’