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Virtual doctor

Author: Paul Hayes

Debate continues as to the quality and efficacy of online prescription, referral and medical certificate services.

The young woman was in tears as she entered her regular GP’s consulting room, soon asking for a referral to a surgeon for a breast augmentation. During the subsequent discussion, it came to light that the young woman’s partner had made it clear her breasts were too small.

However, following a conversation about relationships and body image, the young woman decided she needed time to think things over and discuss the issue with friends, and that she would come back to her GP if she needed further assistance.

Had she instead visited an online medical service, inserted her concerns into a standard questionnaire, she would not have had the opportunity for that private and more familiar interaction. The outcome may have been very different. 

Online services

People go online to do their banking, buy movie tickets, order food, find someone to do their gardening, and for nearly every other thing in their lives. Why, then, should they not do the same when it comes to accessing prescriptions, referrals and medical certificates?

‘The risk with online services performed outside of the usual GP–patient relationship is that they can fragment care and may not provide continuous, comprehensive general practice care to patients,’ Dr Edwin Kruys told Good Practice.

‘The Australian GP model of care has been very successful in keeping Australians well and out of hospital. Patients who maintain strong relationships with a usual GP or practice team experience better health outcomes.

‘Online services should enhance, not dismantle, this successful model.’

These online medical services, such as Qoctor, provide single-event services and can be accessed by anyone, regardless of their medical history.

Prescriptions, referrals and medical certificates may be provided by doctors with no previous knowledge of the patient and minimal information by way of an online questionnaire, and who require no subsequent consultation with the patient. Patients can access some services without speaking to a doctor and are charged a fee (eg $20 for a referral to a specialist).

‘These services cut out access to the holistic elements of general practice,’ Dr Emil Djakic, GP and Deputy Chair of RACGP Expert Committee – General Practice Advocacy and Funding (REC–GPAF), told Good Practice.

‘We train GPs to provide holistic care and these services put in referral systems that ignore the initial elements of providing this type of care.’  

The increasing prevalence of these online services led the RACGP to release a position statement in order to address the dangers the college believes fragment patient care.

‘General practice is characterised by personalised, longitudinal care,’ RACGP President Dr Bastian Seidel said. ‘These online services provide patients with prescriptions, referrals or medical certificates without sufficient understanding of their medical history and social context, which is a safety issue and may affect quality of care.’  

The position statement outlines the RACGP’s key issues on the subject:

  • Online prescription, referral and medical certificate services do not support continuity of care.
  • Online prescription services risk patient safety.
  • Online prescription, referral and medical certificate services compromise quality of care.
  • Online prescription, referral and medical certificate services increase complexity, inefficiency and cost.
  • Online prescription, referral and medical certificate services may be used predominantly as a profit-driven tool.
  • The qualifications of doctors providing general-practice-style online prescription, referral and medical certificate services are unclear. 

Standard questions

There is genuine convenience in the use of online medical services. The possible fragmentation of care, however, can present dangers for patients. In a typical example of a patient using online medical services, Sarah* travelled a risky path to diagnosis.

Having accessed an online healthcare provider, she received a referral for sleep apnoea. Given no practitioner was present, she missed out on the opportunity to have checks on her blood pressure, body mass index (BMI) and cardiovascular risk factors.

Had Sarah presented to her GP in person, he or she would likely have determined that a discussion about weight loss was appropriate; however, this was missed when she bypassed a physical examination for an online consultation.

By using an online referral service with an unknown provider, Sarah was referred directly to a sleep study and recommended continuous positive airway pressure therapy (CPAP). She did not have the opportunity to discuss reversible causes of sleep apnoea and avoid unnecessary steps and treatment.

This type of scenario can lead to contradictory recommendations from unconnected doctors.

‘It becomes a patient safety issue. Without access to the treating GP’s notes, the online doctor has no means of otherwise confirming the information provided,’ Dr Kruys said. ‘There is also no guarantee the patient’s usual GP will be informed following a patient accessing certain online services.’

A more established therapeutic relationship also allows GPs a better understanding of the person sitting in front of them.

According to Dr Nathan Pinskier, GP and Chair of the RACGP Expert Committee – eHealth and Practice Systems (REC–eHPS), informal aspects in more familiar consultations can be key to diagnosis.

‘In a normal consultation with the usual care provider, the provider has access to your medical record and there is a relationship. There are verbal and non-verbal cues that occur during a consultation and those can’t occur online,’ he told Good Practice.

Such a situation – where there is no physical examination and the clock is often ticking – can result in corners being cut, Dr Pinskier argues.

‘If a patient presents [online] with, for example, a sore throat, a headache and a fever, the diagnosis may be an infection,’ he said. ‘It’s very difficult online to determine whether that is viral or bacterial and, because you haven’t conducted an examination, whether or not antibiotics are provided.

‘But, under the pressure of a consultation, given it’s online, it’s more likely than not … that antibiotics might be prescribed.

‘There is a risk that doctors won’t adhere to best practice guidelines.’

Patients, however, may not appreciate such concerns and it is not surprising many want to go online for at least some of their healthcare. 

‘I get the impression that many patients would appreciate conducting more of their healthcare business from home or on the go,’ Dr Kruys said. ‘Used in the right way, online services offer benefits.

‘For example, [there may be benefits] with regards to greater flexibility for GPs, alternative business models, reduced waiting times, less travel time for patients and doctors, and improved access for patients living in rural areas or patients with mobility issues.’

Dr Pinskier agrees that online services can be advantageous, but stressed the ‘used in the right way’ aspect of their integration. In the same way the RACGP is in favour of after-hours healthcare being provided by qualified GPs with a relationship with the patient, so it is with online services.

‘If it integrates into the fabric of general practice, then it can be made to work. Where it’s a deputising arrangement, so your regular doctor is not available and the service has access to the medical notes, is acting as a locum and standing in the shoes of the regular doctor,’ Dr Pinskier said.

‘That can be complementary because they may have some guidance from the practice or the doctor in relation to managing that individual.’ 

Staying in front of the future

According to Dr Aifric Boylan, GP and CEO of Qoctor, online clinics are catering to a specific healthcare need and the general practice profession can benefit from embracing the technology, rather than swimming against the tide.

‘Online healthcare is already happening. It’s not going to be a matter of choosing whether to engage with it,’ she told Good Practice. ‘It’s up to clinicians to be part of the innovation or risk becoming sidelined.

‘Other entities will look to exploit the opportunity of online healthcare, but may not have the same experience or ethos that healthcare professionals can bring to the table.

‘Broadly speaking, people are managing many aspects of their lives online. They are seeking solutions to their health problems via the internet, and the quality of answers and solutions they find depends on whether healthcare professionals are positioned to meet them in this virtual space.’

Dr Boylan believes online healthcare services and the standard questions they pose to patients provide an opportunity to cover areas that may slip through the cracks in the course of a run-of-the-mill consultation.

A standardised digital approach, she argues, helps to ensure every important question is asked in the context of each treatment type.

‘There is no question that online healthcare offers an opportunity to build in comprehensive screening, where all key information is gathered. It can also give the patient time to reflect upon an answer, or to understand why the question is being asked in the first place.’

Dr Pinskier understands the idea that technology can be used in such a way, but warns against the lure of ‘disruption for disruption’s sake’.

‘Uber is championed as a great example of a disruptive technology. That has created access to immediate transport all over the world,’ he said. ‘However, Uber doesn’t turn a profit and it has had problems in London around quality and safety.

‘So some things that may, on the surface, appear to be very desirable and feasible, might have underlying issues that still need to be sorted out.

‘We do need to embrace some of the technology, no question about it. [And] organisations like the RACGP need to be strong and vigilant and develop appropriate standards and processes.’


* Not her real name.