Telehealth’s primary care use case side-swiped by danger money

We must admit that we are still scratching our heads at Australian health minister Greg Hunt’s recent announcement of a new $180 million package to support COVID-19 care in the community in the future. There are some interesting bits, such as the subsidy for pulse oximeters for positive patients to use at home, and a small amount of money for medical deputising services and district nurses to visit COVID patients at home.

But putting aside the fact that there is simply no excess workforce capacity for nurses to visit people at home, let alone GPs – medical deputising services may be in a different boat – nor can we find a compelling reason behind the announcement that GPs will be paid an extra $25 to see COVID-positive or suspected COVID-positive patients face to face, in addition to existing MBS items.

What on earth is this all about? Is the Department of Health actually trying to encourage infectious people to see their GP face to face, when this is not only entirely unnecessary but positively dangerous? As we have been repeatedly told, most people with COVID will have mild to moderate symptoms and they can very much be managed with basic devices and telehealth in their home for the 14 days they need to be in isolation.

There are numerous examples of how this works in Australia and New Zealand, the majority run by hospital services – see here, here, here and here – but quite a few involving remote monitoring by GPs. This is obviously the future, but for some reason the Department of Health seems to want to encourage in-person visits rather than remote, and none of it makes any sense.

The $25 fee on top of normal MBS items seems to just be a danger money payment, or at the least to pay for PPE, but no one is quite sure what it is all about. In an opinion piece in Pulse+IT yesterday, Coviu CEO Silvia Pfeiffer outlines the confusion in the sector about what this new package means, and questions why it is necessary at all.

Dr Pfeiffer is of course the head of a telehealth company and is keen on promoting it, but we are with her: there are few if any better use cases for promoting the benefits – clinical and financial – of remote monitoring and video conferencing than an infectious disease pandemic that can in the most case be handled at home, with severe cases receiving hospitalisation. It beggars belief that the department wants to ignore this in favour of inefficient, unnecessary face to face consults.

The vast majority should be handled remotely. We have in the past railed against the Department of Health’s decision to restrict MBS-funded telehealth to known patients who have seen their GP in the last 12 months, very much at the urging of the AMA and RACGP, whose members could all see the low-hanging fruit of six-minute consults being eaten up by what they call “pop-up” telehealth services.

Perhaps the danger money now being offered is recognition that the AMA and the RACPG got it wrong, that these very same pop-up services that they so decry could in fact be doing a lot of the leg work of people with mild cases of COVID isolated at home, now and into the future. The pop-up clinics could do it for far less money than in person GPs, and they are geared up already for this model of care. Practice-based GPs certainly aren’t. Then again, pigs might fly.

In other news, the Australian Digital Health Agency has awarded a contract to IT services firm Chamonix to build a mobile channel for access to the My Health Record and other ADHA digital initiatives. This makes sense – Chamonix built the original HIPS product that has linked the majority of jurisdictional health systems to the national one, along with the first mobile app connected to MyHR – and it’s pretty clear Chamonix knows what it’s doing. Chamonix and ADHA are also upgrading the HIPS platform that most of state health systems use to upload to the MyHR to make it useful clinicians using mobile devices at the bedside.

It’s no secret but our cynicism about the My Health Record has always been about why it has taken so long to add contemporary functionality. After all, it is more than nine years since the My Health Record went live and mobile is only getting going now. We do understand the dramas over privacy raised by the opt-out debacle and the strict security concerns that come with private health information kept on mobile devices, but we are also aware of a couple of personal health record firms that have gone out of business or are nearing so due to the over-hyped promises in the past. At least it is being fixed, but we do scratch our heads at the time it has taken. There’s missing the boat, and then there’s missing Noah’s ark.

In other late news, NSW has finally got on the real-time prescription monitoring bandwagon and is starting its first phase of a statewide roll out. We have been very critical of NSW in the past for its reticence in getting on top of this initiative, which has very much been led first by Tasmania and then the real mover and shaker in Victoria. South Australia and Queensland then followed, and our understanding is that the ACT is about to go live with its new system shortly. WA is making moves, and the NT says it will.

But the whole reason behind RTPM is that that the most populous states are the ones with the big problem with prescription drug deaths. We are pleased that NSW has joined the technology party – and we think their clinical advice line for GPs and pharmacists, staffed by pain, addiction medicine and mental health experts from St Vincent’s Hospital, is fantastic – but we are also very much aware that while technology can help alert clinicians to potential problems, technology is not the solution. That lies in massive increases in real support for people with addiction, mental health and chronic pain issues. Technology is a mere tool to be used by actual healthcare professionals.

We also hear this week that HealthEngine has put its public float on hold, apparently because it wasn’t going to raise the money it hoped for. That brings us to our poll question from last week, when we asked whether the uptake of the national booking solution provided by HealthEngine was a good or bad result. Most said bad: 73 per cent versus 27 per cent who thought it was a good result.

This week, we ask:

Should the $180m community COVID package have been spent on telehealth and remote monitoring instead?

Vote here or leave your comments below.

Comments  

+1 # Nathan Pinskier 2021-11-13 12:36
Re COVID19 Community Models of Care, can I offer my thoughts regarding the models of care and associated care pathways that could be used to support newly diagnosed COVID19 positive patients in the community:

Whilst it is important from both a relationship and continuity of care perspective that General Practice is involved in the care pathways it is also evident that General Practice by and large is not optimally set-up to provide real-time and continuous monitoring of COVID19 positive patients. This is significant when considering that the health of COVID19 positive patients can in some instances deteriorate rapidly and become life threatening.

Whilst some, perhaps many GPs and practices with the best of intentions may offer to care for COVID19 patients they may find themselves in a position to be unable to deliver a continuing level of monitoring and care for a disease with highly random symptomatology. Many practices and their teams are already overworked and COVID19 exhausted. The capacity to accommodate additional urgent appointments in a timely fashion will be variable and possibly limited. This is likely to become a significant problem especially in the after-hours period, unsociable hours and on weekends.

It is therefore critical that when approaching General Practices and Practitioners with a request to manage COVID19 positive patients that a nuanced approach Is adopted. GPs should be able to indicate not only if they are prepared to monitor patients but whether they require additional support to do so. They should be provided with a series of options regarding what form the support could take.

The options might include any of the following:

Full care by the GP/Practice 24 x 7
A hybrid care model - in hours support with outsourcing care after-hours via a third party healthcare provider
Complete outsourcing to a third party healthcare provider

Given my background as a GP, a past chair of the RACGP ehealth committee and also as the immediate past president of the General Practice Deputising Association I am firmly of the view that any care solutions involving third party health providers should include the requirement for that provider to transmit periodic reports back to the nominated GP/practice. This could be achieved by the use of event summaries sent via secure messaging. These event summaries could also be uploaded to My Health Record.

Regardless of the care pathway adopted for any individual patient, it is my view that the system must be supported by third party medical teams can deliver the required supervision and interventions at any time. The alternative, I fear, is that some COVID19 positive patients may fall between the gaps exposing them to unacceptable healthcare risks. In addition, it risks unnecessarily increasing the burden on the 000 service, ambulance services and emergency departments as highly anxious patients grow increasingly desperate.
0 # Kate McDonald 2021-11-19 11:33
Should the $180m community COVID package have been spent on telehealth and remote monitoring instead? The vast majority agreed: 92 per cent said yes, just eight per cent voted no. We also asked for your thoughts:

- We need both the pulse oximeters and the remote patient monitoring. If only nurses would get reimbursed for telehealth, then the $180m would be used sensibly.

- Sets us up for the future

- Accelerate adoption of digital capabilities.

- Most COVID patients can and should be monitored at home, it would be better for all the community,.

- Telehealth provides far greater benefits to a broader cross section of the community and world provide a platform for better long term acceptance by both practitioners and consumers.
- Managing Covid pts needs more than a pulse oximeter, patients need proper remote patient monitoring where there are answering a Covid question set and also putting in vital signs more than just oximeter results

- LEADING QUESTION - WHY SPEND $180m AT ALL?
(but the covid package is the bigger waste of public money imo)
The DoH is currently being run by the AMA and RACGP, this needs to stop!

- Telehealth gets sick people to the doctor as the physical effort is much much less. So no, telehealth is a better spend.

- Safety

- A bit of a no brainer, don’t move potentially infectious folk around the community.

- Best use of funds to support the most people overall and imbed innovative models of care for the long haul

- Mental health

- You either make the assessment that General Practice will be part of the solution or you determine that there’s a whole new way to work. If there’s a whole new way to work, will we junk General Practice abs start again? Better to fix the model that you’ve broken than introduce another broken model on top of the old one. Get real.

- Because the pandemic has taught us that the combined use of telehealth with remote monitoring is effective for managing mild to moderately unwell patients outside of hospital. This is the future but requires that all of the stakeholders combine to ensure that it can be made to work and that the way the money flows does not instead inadvertently creates silos

- GP income, practice modifications

- Citizen’s want Telehealth to be a permanent and expanded part of the health care offering. ( banks had to move away from branches in the 1990’s and offer telephone, internet banking etc). Consumers demand convenience. Being forced to go into a clinic when the situation does not warrant it is “head in the sand” stuff.

- For the safety of doctors and nurses, plus to overcome the chronic shortage of nurses.

- Infection control and escalating GPs use and consumers access video telehealth. It would help it embed into everyday care and ots use for other conditions

- Because long COVID requires integrated local health and care services plus peer support.

- relying on nurse visits in a nurse resource constrained environment doesn’t make sense

- The health system has never got past GP Business model protection through interest groups and narrow use of technology.

- The remote monitoring platform, program and processes for COVID care could be the catalyst for general practice to implement remote monitoring for other conditions, and increase the digital health lessons of the pandemic. Sadly a missed opportunity

- Remote monitoring via Alcidions MIYA technology would be far more effective and cost efficient .

- Safer option for all concerned

- Better use of the money and more likely to benefit the patient. Unlikely to happen, too practical.

- No real advantage to the proposed package.

- Telehealth is the best way to treat mild/moderate COVID positive patients that reduces the risk of spreading to others. Sitting these patients in GP waiting rooms with other patients and staff is the dumbest idea I have heard in a long time. Just goes to show how powerful these lobby groups really are!

- better efficiency

- I believe the Community Service providers that offer nursing services and remote health monitoring in a person's home are being overlooked and this would be a more effective use of resources with reduced risk. As a Community Nurse Provider, we already conduct home visits and can support clients with Telehealth services. We still have the wrong model - it is a medical model as has been discussed in previous Productivity Commission reviews. Disappointing response yet again from our government.

- It's more efficient way of providing healthcare for these patients. Less stress for the patient too. I can imagine getting "dirty" looks when I arrive at a general practice for COVID-19 treatment.

- Keeping all in the community safe, working with the current workforce which is already at a stretch.

- Why would anyone logically fund a face to face visit by a GP for a covid patient? All health services are using tele-health and remote monitoring. Makes no sense

- Better use of limited resources to the benefit of patient and care provider.

- reimbursement of purchase of in practice point of care tests for diabetes, heart failure and CRP tests for sick kids and also adults with exacerbation of chronic lung disease

- to encourage uptake of video telehealth systems over phone. Also why can't the Dept and Minister of Health rationalise the item numbers, for x sake. The tripling of item numbers in our practice, each with their separate limitations and rules has increased the stress and admin and compliance burden very significantly. Such ill considered innovations provide a stead additional cost to practice every day. Why not use the standard item with a v or p on the end. Shocking idea, I know.

- For most consumers, purchase of a pulse oximeter will be a waste of money - they should be available for loan or rent and should be remotely monitored as most consumers can't interpret oximetry data - if it starts to deteriorate in a young patient, there is no time for delay or error.

- maintain safety for all needing to visit the GP clinic - nurse led models of support need to be funded. Many other needs of those isolating can be identified and sorted without direct contact - especially when non medical needs are critical to line up to keep people isolating and feeling connected - social workers would be ideal for this too working with the medical staff.
It is not safe to see a COVID positive patient in a practice as it puts the whole practice at risk and on top of this the cost of the lost time to facilitate the appt, the cost of PPE for the Dr and staff and the cost of additional infection control cleaning far out weighs the $25 offered. Access for treatment of a COVID positive patient is more suited to Telehealth or if more severe, attendance at a hospital.

- could use the money and upgrade telehealth capability in regional areas

- Our patients don't have cars and would have to travel by public transport to be seen. That is a very unsafe proposition for the general public using public transport.

- Risks of covid infectious patients in practice setting are too great on so many levels

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