GP to patient video consults part of the mix: Skype2doctor

The founder of the new Skype2doctor telehealth service has moved to allay fears that it will disrupt the traditional doctor-patient relationship, saying it will not detract from face-to-face consultations but will be simply another way to deliver healthcare to patients.

Dr James Freeman, who founded the GP2U telehealth service for specialist consultations that are currently subsidised under the government's telehealth program, said Skype2doctor was merely an extension of this new mode of practice and would provide a mechanism for any Australian GP to deliver telehealth care to any patient.

Skype2doctor is due to officially launch next week and will provide a platform for GPs working from home to offer paid video consultations to patients. All the GP will need is a Skype account, a computer, a printer and PBS prescription paper.

The company has devised a fee schedule based on the Australian Medical Association's recommended structure, although GPs are free to set their own fees. Patients simply pay by PayPal or credit card.

While the early details of the new service have come in for some criticism from the AMA and the RACGP, Dr Freeman pointed out that several organisations had called for the telehealth rebate to be extended to GPs providing care to people in aged care facilities and those at home with mobility issues, and this is exactly what Skype2doctor would enable, albeit as a paid service.

He said the impetus for launching Skype2doctor was a discussion with another doctor who was thinking of setting up a video conference-based service for tourists and expats in Bali. That idea was not feasible due to practical issues of prescribing medications, so instead he turned his attention to the Australian market.

“If you look at a typical GP consult, 90 per cent of the time you get reassurance, 70 per cent of the time you get a script written, 10 per cent of the time you get a medical certificate, 10 per cent of the time investigations, and five per cent of the time a referral – that's the rough breakdown,” Dr Freeman said.

“A lot of GP work is psychology and psychiatry – 40 per cent of telehealth has been psychiatry and no one argues with that or that you can't do a great job via telehealth. With GP counselling – again you can do a great job.

“That's already 12 million consults a year in that category. There's no doubt that you can't do everything by telehealth but there certainly are areas that you can do and I think that's a discussion for the profession and the public as to what actually works.”

Dr Freeman said the main logistical issue the new service had to overcome was the prescribing and dispensing of medications. Skype2doctor has signed an agreement with Terry White Chemists to allow GPs to automatically fax a script to a local Terry White pharmacy or to deliver medications by courier through its online service. Scripts can also be sent to the patient in the post.

The agreement is not limited to Terry White Chemists, as it was merely the first large chain to sign up, and Dr Freeman said the company was currently in discussions with several other pharmacy groups to get them on board as well.

“It was clear that medication was going to be a key component of this,” he said. “You have to think about how you get medicines to a patient who is not in front of you.”

Under current prescribing and dispensing regulations, scripts must be written on PBS paper in order for the rebate to be refunded to pharmacists, so GPs taking part in the service will simply prescribe in the normal manner.

With prescriptions, patients are offered three distinct options, Dr Freeman said. "They can elect for the doctor to post the script to their home, allowing the patient to choose any pharmacy to have it filled.

"They can select a nearby local pharmacy from a Google map and have the script immediately faxed through for pick up, or they can elect to have the prescription fulfilled online by terrywhitechemists.com.au, who will arrange for it to be home-delivered. In all cases a paper PBS script, hand-signed by the treating doctor, is delivered to the necessary location."

Under current dispensing regulations, both bricks-and-mortar and online pharmacies are allowed to dispense drugs if they have a facsimile copy of the script, as long as the original is then posted to them.

“Because this is a premium service you have to offer better than what you can get and the advantage here for the pharmacy is that you can get the script before the patient is there and you can work at your usual rate,” Dr Freeman said.

“For the patient the service is tremendous because they can go in, grab the medication and off you go. The third way is through an online pharmacy and they have the ability of delivering door to door.”

For the GP, one of the benefits of the Skype2doctor service is that it has already created an online patient management system that is used for its GP2U clients. The PMS looks and functions exactly like common GP desktop software like Best Practice, Dr Freeman said.

It has access to MIMS Online, patient notes, referral letter templates and RACGP guidelines, and the only difference is that it's hosted online.

Clinical notes are stored in a database behind a Defence Signals Directorate (DSD)-grade gateway, and while the service has sandbox access to the PCEHR, it is not likely that notes will be uploaded in the near future, Dr Freeman said,

"GP2U would love to use the PCEHR as a medium to communicate notes with existing systems but sadly the low uptake of the PCEHR associated with its opt-in nature means that at this stage it can't be used for that purpose. It would be great if the PCEHR was opt out and software vendors could know there was a 99 per cent chance a patient has one, rather than a 99 per cent chance they don't."

He said when GP2U was being established, store and forward was the favoured approach, so the creation of a secure medical record was quite easy. "Dermatology was one of the early uptakes of that as a way of getting clinical images from a GP to a specialist so we have built a secure record system within a secure account,” he said.

“You can arbitrarily add any file you like including clinical images and DB4 forms the patient has signed, so a patient's medical record is perfectly feasible there as well. The patient can also take a copy of it and do as they wish.”

Skype2doctor is offering a full managed service to GPs, including the patient management system and online appointment bookings. When the GP lists their free appointments, it will also list the fees charged.

“There is a recommended fee schedule which is $30 for five minutes, $50 for 10, $70 for 15 – that is $4 a minute plus a $10 flagfall,” Dr Freeman said.

“That is in line with the AMA's recommended fee which is $71 for a standard consult and $130 if it is more than 20 minutes. We think that is a price point that is reasonable, but the GP sets their own fees and their own hours and they work in a way that fits in with their lifestyle.”

He said the company would run the service just like any other managed practice, with the bulk of the fee going to the GP and a small percentage to Skype2doctor.

From the patient's end, they simply have to register to use the service and are able to choose a GP by appointment time, location, gender, languages spoken or services offered. Skype2doctor has a virtual waiting room in which the patient is informed if the doctor is on time or running late, and just like a physical waiting room there is access to a range of newspapers, magazines and TV websites, and even National Geographic online.

“We were going to put a 1969 National Geographic there just for a joke but I'm told my jokes aren't as funny as I think they are,” Dr Freeman said.

The patient also fills out a questionnaire with medical history, allergies and medications, along with details of their complaint. The questionnaire is stored as part of the patient's file, and doctors can access both the file and previous consultations the next time a patient books in.

Dr Freeman and his team believe there is a large market out there for this kind of service, in terms of both patients and GPs willing to offer their services. The patient market includes mothers of young children as well as time-poor professionals, and the GP workforce includes the stereotypical 'lady GP' at home with children, along with semi-retired GPs.

“Lady GPs say they sometimes refer to it as 'tears and smears' – there is a lot of low-grade psychiatry and psychology, a lot of counselling involved in female GP work. This is of course radical stereotyping but it is real. It fits perfectly time-wise but it also fits in with people at home after hours. We were originally going to just run from 7am to 7pm but a lot of GPs are saying can we do it 8pm to 10pm, which is not a bad time to be doing it.”

There is also no reason why full-time GPs working in a practice could not offer to conduct one or two video consults a day if they have no-shows or a break in their schedule, he said.

Routine repeat scripts for things like the contraceptive pill or consultations with patients embarrassed about certain disorders, particularly depression, are obvious interventions that can be done by video consultation.

Routine checks of blood pressure and repeat scripts of blood pressure drugs are another – patients can buy blood pressure monitors for $30 these days, or get their blood pressure taken for free at a pharmacy – but one area that Dr Freeman sees as particularly important is palliative care in the home.

“There is at least a generation of doctors who don't do home visits and GPs are not going to start doing it again,” he says. “Somebody dying at home – they get pain and either they get enough narcotic or they go into hospital for the pain. If they get enough narcotics the next problem they face is bowel problems. Families don't deal well with that – there is the psychological distress of the family.

“Telehealth can deliver very effectively a daily morning visit from a GP asking how's it going, saying 'okay, up the morphine by another 5mls three times a day or whatever, how are the bowels going, take more Lactulose, how are you going, how's the family, do you want to come in and see us …'

“That would help the problem we see at the moment where people spend their last two weeks of life in the acute care system. If you can keep those people out of hospital even for a day it is worth it but if you keep them out for the full two weeks, they get to spend their last days at home with their family, they don't get put in hospital and stung with needles by interns because hospital doctors think they should be doing something because they can, rather than just allowing the process to occur.

“It would be much better if there was one doctor getting a $35 rebate from Medicare as opposed to a $1600 acute care bed.”

Balancing supply and demand will be the main issue for the success of the service, Dr Freeman believes. If there is too much patient demand there will be no available appointments; too much supply of doctors and they won't do it because they won't earn an income, he said.

“It is quite interesting how we will tackle that. We are looking at mixed appointment times so there might be more expensive appointments available at certain times.

“We were initially looking at small numbers but the Daily Telegraph did a poll and they found that with 5000 people voting, 1600 said yes. That's 33.9 per cent saying they'd see a GP online. I think the demand will, after the initial slow period of getting it out there in view, be quite substantive.”

There has been some criticism that many of the consults will result in the doctor simply telling the patient to see a doctor in person or go to hospital, but Dr Freeman believes that is something that doctors and patients should work out between themselves.

“If you see a doctor online and they say you need to physically see a doctor or go to the emergency department, you could see that as a failure of telehealth or you could see it as a very rapid rendering of healthcare,” he said.

“Some of the time people will be told to go and see a doctor and sometimes they will be reassured. People say you can't do (counselling) over the phone but you can – you just can't get paid for it. It may not be a huge part of the market but it should be part of the mix.

“Accepting that face-to-face care, is, and will remain, the gold standard should not preclude us from exploring the opportunity telehealth offers to enhance patient care. Just because telehealth can't do everything doesn’t mean it shouldn’t do something.”

Posted in Australian eHealth

Comments   

# A/Prof. Terry Hannan 2013-01-09 11:22
A colleague of mine has been using Skype consults for ~ 2 years with more than 80-90 encounters. His relationship with the Primary Care practitioners is increased as well as with the patients. Patients are commonly in the Skype conultation. Less hospital visits, more cost effective care and enhanced communication have been the outcomes. Feel free to contact this physician who has a pending UTAS interview on this topic. His name is Dr Jorge do Campo jorge.doCampo@dhhs.tas.gov.au
# Andrew Johns 2013-01-30 12:03
Skype is not secure and should not be used in this way. Skype negotiates traffic flow using a proprietary method and if the 2 end points cannot directly connect to each other, then the traffic is routed via a third party. You have no choice over who this 3rd party is, nor where they are located. If outside Australian borders, then it is illegal. No independant security review has ever been published other than a Skype-paid review of an extremely old version. Since purchase by MS (a USA based company) the Patriot Act requires the US gov to have accessto the traffic, a clear violation of the Aust Privacy Act w.r.t patient records. The only way to ensure direct connectivity is if one end of the link is configured in an insecure manner (ie:to allow unauthenticated UDP packets to enter your computer from the internet). Remember SQL Slammer anyone - a single packet UDP attack that took down a significant number of ser vices, eg:both ISP's providing ATM connectivity for Bank of America...
# Andrew Johns 2013-02-22 13:56
From
http://www.skype.com/en/legal/business-tou/#disclaimers

13.1.1 ... SKYPE FURTHER DOES NOT REPRESENT OR WARRANT THAT THE SKYPE PRODUCTS WILL ALWAYS BE ... SECURE

and from

http://thenextweb.com/microsoft/2012/11/14/security-hole-allows-anyone-to-hijack-your-skype-account-using-only-your-email-address/

I think the URL says it all. See below for more.
# Andrew Johns 2013-02-22 13:57
Continuing from above
from: http://www.theregister.co.uk/2013/01/25/activists_demand_skype_transparency/

...statements about the confidentiality of Skype conversations have been "persistently unclear and confusing," casting the security and privacy of the Skype platform in doubt.

... both Microsoft and Skype have refused to answer questions about ... whether Skype conversations can be intercepted. [and so it can only be assumed that it can be intercepted, hence the 'security' is just posturing]

So, if you have no concerns over your privacy, go right ahead and use it, but as an IT Security Professional, I *strongly* recommend against using it for this purpose.

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