Telstra hoses down AMA concerns over continuity of care

Telstra Health has responded to criticisms from the Australian Medical Association (AMA) over its new ReadyCare telehealth service, saying the plan is to offer it to GPs to use with their existing patients.

AMA president Brian Owler criticised Telstra's plan following its launch this week, telling AAP that it was a “cynical and inappropriate way” for Telstra to be involved in healthcare.

Professor Owler said the AMA supported telemedicine only where a patient already has a relationship with the doctor.

"We want people to maintain a regular contact with their GP, not just ring someone out of the blue,” he said. "They can just ring up a number, and get a doctor on the other end that they have no knowledge of or relationship with, and get scripts and other treatments prescribed.”

Telstra Health managing director Shane Solomon said the new service has been designed in two phases to ensure continuity of care, and the plan was to offer it to GPs, particularly in rural and remote areas, who are already using telehealth.

“How we are phasing it is in fact heading towards where the AMA wants to be,” Mr Solomon said. “Part one is to establish the service as a credible, safe, national service, so people can see that it works, that there is consumer demand for it and it can be done safely.

“Part of that is we have committed to message the person's regular GP. The AMA said that's not enough and I understand where they're coming from, so phase two ... is to work with a limited number of GPs, and particularly with [the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine (ACRRM)], to adapt the platform so that GPs in their local practices can do telemedicine safely with their own patients.”

He used the example of prominent rural GP, Bruce Chater, a member of Telstra Health's medical advisory panel, who practices in the small town of Theodore in central Queensland.

“[Dr Chater] realises that if it's a repeat prescription or it's a minor ailment, to get someone to travel an hour or two hours or three hours into Theodore is crazy,” Mr Solomon said.

“The problem is they do it but they don't get paid for it, so we believe that the contribution we will make ultimately will be to have this form of GP service accepted as a normal part of practice in the national Medicare system."

In a statement provided to Pulse+IT, a spokesperson for ACRRM has distanced the college from Telstra's telehealth plans, saying it has not had the opportunity to properly consider the arrangements.

"Telstra has indicated that we will be properly briefed at a workshop which has yet to occur. The ACRRM board has not had the opportunity to consider what Telstra is proposing, let alone provide endorsement.

"Telehealth should enhance the existing primary clinician-patient relationship, not fragment it. Telehealth arrangements should complement existing specialist services (where available), build on rural workforce and referral patterns to avoid further service fragmentation, and address practicalities of coordination, scheduling and support from the patient’s perspective to improve their continuity of care."

Mr Solomon said the plan was to provide a full end-to-end service, which is why Telstra has chosen to partner with the Swiss company Medgate, which has been operating for 13 years. Proof that the system works in another jurisdiction was essential to its acceptance here, he said.

“We'll adapt the guidelines for Australian purposes and there are other adaptations, but basically you have to stand up the service as a stand-alone service in the first instance. Our ambition is to introduce this to Australia and give it credibility that would ultimately allow local GPs to use it.

“I would qualify that by saying the Commonwealth has a legitimate concern that people will just ring up Mrs Smith and say how are you today and call that telemedicine, but in Switzerland the way they have handled that is to have an accreditation program.

“We would love to have a vision where the college of GPs and the college of rural and remote medicine offer training in telemedicine so they can be accredited as telemedicine providers.”

He said the plan to offer it to GPs to use in their own practice would address the continuity of care issue that the AMA is concerned about. “We are partly addressing that continuity of care issue in phase one by making sure that that we send back to the regular GP information about a telemedicine service a person might have received.”

While he could not speculate, the establishment of a safe, efficient telehealth service that was accepted by GPs would go a long way towards encouraging the federal government to allow telehealth to be considered the same as a face-to-face consultation for the purposes of the MBS.

The technology

Mr Solomon also provided more detail on how he expected the system to work in Australia. ReadyCare will involve the full offering from Medgate, which includes telemedicine-specific call management, forecasting and demand management, patient management software, protocols and performance management.

The protocols and guidelines will be adapted to the Australian setting, but the initial piece of work will involve adapting the clinical software to the expectations of Australian doctors. Mr Solomon said Australian GPs would not find the clinical software used in Switzerland adequate for their purposes.

“We've had the IT people out from Medgate already – they have been out here for two weeks sorting through whether we have to adapt the system to suit our circumstances,” he said. “The conclusion is that Australia's GP clinical software is far superior to that in Switzerland, and Australian GPs working with this would not find it adequate, so we are sending a couple of people over next week to do a detailed specification.

“We will have to adapt it, and because it is linked in with the workflows of Medgate, there is a piece of integration that we have to do.”

He said Medgate's scheduling system made the service “incredibly efficient”. The company has also built an app for common minor ailments like skin rashes so patients can upload a photo directly into Medgate's system in advance of a consult with a doctor.

“The service promise is that something like 90 per cent of people will get a GP to call back in 30 minutes, [but] if they need to collect clinical information then it is a bit longer. All of their systems and the guidelines are built into this scheduling system.

“We are bringing the full system here but they will be adapted for Australian circumstances. I think that illustrates how important it is for Telstra Health to have both the health IT provider application capability as well as the telehealth capability.”

Medgate has a relatively basic method for prescriptions, in which a script is faxed to the patient's pharmacy of choice and the paper script sent later. Mr Solomon said Telstra intended to start with that method in advance of much hoped for changes to legislation that will allow paperless prescribing here.

Telstra is also looking at the legislation covering what the private insurance sector can involve itself in for out-of-hospital care. In Switzerland, Medgate consultations are paid for by insurers, which under its social insurance system is subsidised by the government.

There are a number of potential payment models that Telstra is investigating in advance of federal moves to add GP-to-patient telehealth to the MBS.

“Insurance for primary healthcare regulations are about not being able to insure for something that Medicare covers,” he said. “We are looking at it but we think that there is potential here to follow one of the Swiss options which is a subscription-type model. So for a year it might cost you €150 for unlimited telemedicine access. We are looking at the legality of all that sort of thing now.”

He said Telstra would look at outsourcing the hiring of GPs to provide the consultations - several private insurance companies already have panels of salaried doctors on staff - and it would also explore how to offer the ReadyCare service to existing offerings like Healthdirect.

Telstra Health plans to have ReadyCare ready for launch in nine to 12 months.

GP reaction

Prominent GPs and eHealth advisors Mukesh Haikerwal and Nathan Pinskier gave qualified support to Telstra's plans.

Dr Haikerwal said it was good to see a company like Telstra becoming actively involved in healthcare using technology, which is its forte.

“It’s good to have a big player that can stare down government and really advocate on behalf of us as consumers and patients and us as clinicians, rather than us having to acquiesce to government mood all the time,” he said.

He said while telehealth had existed in Australia for some time, it doesn't work well for primary care in general.

“We’ve had telehealth in Australia but it has not worked previously because it was only available for psychiatry. Then it was available in a widespread way with the election of the Gillard government. And that was an abject failure, because the systems were not in place to make it work well and there are no standards.

”Telehealth can work well and does work well in places like Canada where the Ontario telehealth system works very well, but it takes time to get there. The issue is how is it going to integrate with current general practice.

“If there is a move to have a standalone call centre like the healthcare system, but doing the work of GPs by remote control, there will be some significant backlash I believe from the clinical community.

“Ultimately any enhancement of the capacity to do technology in the health space is to be welcomed, but it needs to be working in a good partnership relationship with existing services, rather than trying to cannibalise them.”

Dr Pinskier said that from an informatics perspective, one of the challenges would be to decide where telehealth would fit in in terms of GPs' working process.

“I think it is fair to say that many general practices have struggled to integrate telehealth in their existing work practice, because they are already work-overloaded and they are unable to set aside the dedicated facilities or time," Dr Pinskier said.

“There’s a question also not just around the standards, but how does it conflict with the existing medical home model, how does it compete with all the other telehealth services that currently exist around the country. How does the consumer decide? How does the consumer determine which ones are clinically accredited, clinically safe, that integrate with my regular care provider?

“So there’s a whole lot of questions I think remain unanswered and probably the biggest single question is the one around cost. Does it potentially lead to a two-tier model? Because if it’s not funded through the MBS, that means that consumers that can afford to pay are proportionally advantaged, whereas others are proportionally disadvantaged. If it is funded through the MBS, does it actually change the existing provider relationships that exist?

"The technology, as Mukesh has said, is exciting but it has been around for a while. It’s just a question of how you integrate it.”

Posted in Australian eHealth

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