Why are Australian GPs doing relatively few video consultations?

In May and June this year, only three per cent of GP telehealth consultations were conducted by video conference, despite the two Australian GP colleges and Medicare all stating a preference for the use of video rather than phone as a substitute for an in-person consultation.

Statistics derived from Medicare data for May and June 2020 show that about a third of GP consultations were by telehealth. Of this:

  • 97 per cent of GP telehealth consultations were by phone
  • The number of video consultations was highest for patients in the 25-44 age group (consistent with age group distribution in the Australian population)
  • The proportion of telehealth consultations for females was higher than the proportion of in-person consultations for females. Conversely, the proportion of telehealth consultations for males was lower than the proportion of in-person consultations for males.

Medicare has not yet reported data for July 2020.

The use of telehealth in general practice has increased worldwide since the onset of the global COVID-19 pandemic. This seems to have been primarily in response to the imperative to reduce the risk of transmitting SARS-CoV-2 infection, a risk that is obviously inherent in in-person consultations, even with personal protective equipment (PPE).

This increase in the uptake of telehealth in general practice has been observed across many countries, with different health systems, different funding models, and different economies. However, there are few data and published reports on telehealth and general practice in the COVID-19 era.

In Australia, we have been able to access, analyse, and report data on video consultations and phone consultations, as these are linked to the temporary COVID-19 Medicare item numbers introduced on 13 March 2020.

International comparison

The UK National Health Service also reports some data. In July this year, the NHS reported that for general practice appointments in England, 50 per cent were in person, 45 per cent were by phone, 0.4 per cent were online, and 4.6 per cent were by ‘other modes’.

There are two caveats in interpreting these data. Firstly, the data are for appointments with GPs and with practice nurses. Fifty-two per cent of these appointments were with GPs but there is no breakdown of the mode of appointment by GP and by practice nurse.

Secondly, ‘online’ appointments include both video consultations and non-video online consultations such as webchat and voice over internet protocol (VOIP) calls.

Currently, no data have been reported on the uptake of video consultations in general practice in the COVID-19 era in the USA, Canada, NZ, India, China, or countries in Africa. Articles in the press in all these countries report that the uptake of telehealth has been ‘high’, but this has not been defined, and it is not known what proportion of telehealth encounters are by phone or by video.

In a recent article in The Conversation on Canada's experience, Ahmad Khalid argues that telehealth should be the primary way to deliver healthcare in Canada for four reasons: improved access to care; more efficient clinical practices; evidence-based decision making; and financial savings for individuals and for the health system.

As an interesting international perspective, one of the champions of telehealth in the USA is Donald Trump. In March this year, Mr Trump introduced changes which led to the Centers for Medicare and Medicaid Services (CMS) funding telehealth services for people in rural areas and for people over 65; and the Department of Health and Human Services relaxing federal privacy laws, allowing providers and patients to use everyday platforms such as Skype and FaceTime.

The role and advantages of telehealth

With the impetus of the global COVID-19 pandemic, and the imperative to provide non-in-person consultations, telehealth has become integral to general practice in Australia for treating patients:

  • with COVID-19 (85 per cent of patients with COVID-19 are managed in the community)
  • with suspected COVID-19
  • at increased risk for COVID-19 and/or its complications (‘vulnerable patients’)
  • who want to reduce the risk of getting SARS-CoV-2 from attending a general practice
  • who are worried about any aspect of COVID-19 and its effects (physical, mental, and social)
  • across the spectrum of general practice (acute care, chronic disease management, preventive activities, etc).

Telehealth also enables GPs to work from home, and to avoid in-person consultations. This is important for GPs who are at increased risk of getting COVID-19 and/or its complications, due to their age or due to disease, and for GPs who plan to continue to work when in quarantine or self-isolation.

In many instances, a video consultation has advantages over an in-person consultation, and advantages over an audio-only consultation.

Video consultations enable rapport, indirect physical examination, and mental state examination. A video consultation enables observation and interpretation of the GP’s and the patient’s facial expressions and non-verbal language.

Patients can send photos and files to the GP, securely and encrypted, through the video link. GPs can similarly send the following to the patient photos, files, referrals, investigation requests, patient instructions and information. However, prescriptions should not be sent to patients electronically; they can be sent to pharmacies by email (if ePrescribing is not available).

Although video cannot be the default mode of consultation in general practice, it can be considered as an alternative to any in-person consultation that does not require direct physical examination.

The uptake of telehealth, and Medicare

It is easy to speculate about the facilitators and barriers to the uptake of video for non-in-person consultations in general practice in Australia. I have described these in an article in Insight+.

Barriers for GPs include: negative attitudes to video; unfamiliarity with video; the perception that the time taken to set up a video consultation will encroach on the time available to attend to the patient; interruption and/or disruption to workflows in the clinic; low competence and/or low confidence with the technology, equipment, and software; and “it’s easier to pick up the phone”.

It seems likely that that the uptake of video in general practice will increase with time and familiarity. Specialists have been using telehealth since Medicare introduced specialist telehealth item numbers in 2011, and based on May 2020 data, 16 per cent of specialist COVID-19 non-in-person attendance item numbers were for video, compared with three per cent for GPs.

The COVID-19 temporary MBS telehealth item numbers are due to expire on 30 September 2020. What happens next is unclear; the Australian Medical Association (AMA), the Australian College of Rural and Remote Medicine (ACRRM), and the Royal Australian College of General Practitioners (RACGP) have been advocating on behalf of GPs for the retention of telehealth services.

Summary

Since the introduction of the COVID-19 temporary MBS telehealth service item numbers in March 2020, telehealth has evolved to become an integral part of Australian general practice. Telehealth will have a developing and ongoing role in pan-COVID and post-COVID general practice, in Australia and worldwide.

The Australian government must recognise this, by retaining and enhancing telehealth in general practice.

GPs should consider increasing their use of video for consultations for patients who have COVID-19, and for patients across the spectrum of general practice. GPs have a role in providing support and advocacy for their patients to use video for consultations.

ACRRM and the RACGP have published guidelines on the implementation and use of video in general practice.

ACRRM and RACGP should scale up their support for video in general practice by providing advocacy, and by providing online workshops and online modules for professional development, so that GPs can upskill in video consultations.

Further research is desperately required to evaluate the role of video consultations in general practice, and to inform ongoing development.

Dr Andrew Baird is a general practitioner at the Elwood Family Clinic in Victoria and a tutor at the University of Melbourne's medical school.


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Posted in Australian eHealth

Tags: Telehealth, COVID-19

Comments  

+1 # Rob Hosking 2020-09-01 16:32
I support video consulting, BUT, I think we need to carefully analyse a preference fo telephone or video and also, why we don’t have significant asynchronous on line communication (like email or messaging).
How often do the advocates of video consulting use video to talk to their family or friends? Many GPs are using telephone to communicate with patients they already know well and about issues that do not require a physical examination. Telephone is perfectly adequate for these situations. We need to be careful we don’t create a digital divide by insisting on use of video when a significant proportion of the community struggle to use the technology for a variety of reasons.
I see video has benefits if you are unfamiliar with the patient, if they have an infectious disease you don’t want to catch, or them to spread, AND you need to get some visual feedback on their well being. However, this is not the majority of situations.
+1 # Anton Cush 2020-09-02 08:36
Yes we need a decent store and forward option too Rob, to be baked into chronic disease management especially.
0 # Andrew 2020-09-02 10:39
Absolutely agree. UK has this. I don't know about other countries. Does anyone know? What about NZ?
0 # Andrew 2020-09-02 07:34
Video consultations as a percentage of telehealth consultations: 3% for GPs, 16% for specialists.

I had suggested that one reason for this discrepancy could be that specialists are more familiar with video. Specialist telehealth (video only) item numbers were introduced in 2011 (principally for remote, rural, and regional patients accessing distant specialist care).

However, a colleague has suggested that another reason could be that specialists are more likely to use their own laptop/other device as they are more likely to be peripatetic across multiple sites, and to take their laptop/device with them. GPs are more likely to work at only one site, and their clinic computer system may not be appropriate for video consultations (eg desktop computer with no webcam, not possible to connect a laptop to the practice network/interne t access).

Currently, it's virtually impossible to buy a webcam. If anyone knows how to get one, please let us know.
0 # Australian Red Cross Blood Service 2020-09-02 08:47
I bought one in Office Works last week :-)
0 # Andrew 2020-09-02 10:37
Well done! Do you want to sell it? :-) What model? I'm looking for the Logitech C922 which seems to be the Rolls-Royce of webcams
+1 # Jane Connolly 2020-09-03 15:05
Hi Andrew.
Harris Technology has 10 in stock :-)
https://www.ht.com.au/part/BH007-Logitech-C922-Pro-Stream-Webcam/detail.hts
0 # Andrew 2020-09-04 07:44
Fantastic! Thanks very much for the tip. I'll get one
0 # Andrew 2020-09-02 07:48
Thanks very much, Rob, I agree.

I suspect that the main reason why we don't use asynchronous online communication is because it's not funded. It's funded in UK as part of the NHS GP contract - and evaluation indicates that it's very useful, and that it's valued by GPs and by patients. Like some GPs, I use non-funded 'user pays' asynchronous online communication via Ozdocsonline, and some patients are very happy to pay for this for the benefits of convenience and rapid response. It is possible to use webchat through a video call, although one really couldn't call that a true 'video' call if the video stream isn't being used. I have used webchat via Telegram with patients (end to end encryption), but this has been a freebie.

I still believe that video consultations are a new paradigm in doctor-patient communication - not just an inferior version of an in-person consultation, or a phone consultation with moving images. A phone consultation has always been a phone consultation, and always will be a phone consultation, and we will continue to use phone consultations (appropriately) whether funded by Medicare, funded by patients (no Medicare benefit) or funded by us (as freebies). I think there are clear limitations around the suitability of phone for a consultation.

Video enables rapport, non-verbal communication both ways (difficult to express empathy exclusively by phone), indirect physical examination (including the all-important eyeball assessment), etc, I can expand on this ad nauseam.
+1 # Phil Tideman 2020-09-05 11:56
Excellent article. I fully agree that video consultation is a new paradigm. It is also important to understand that specialist / consultant physician use of this platform for rural and remote patients is quite different from the evolving use of telehealth by GPs. Remote specialist video consultation is structured around a patient supported model in which a GP or, as in 99.9% of my VCs, a practice nurse is with the patient at the remote site, which importantly is funded (telehealth Medicare items for both ends). This enables routine observations and simple tests such as the ECG (and an expanding number of other remote examination aids) to be included in the consultation, and if properly structured gives me access to relevant content (medication list, pathology etc) in the GPs practice software through the nurse at the patient end, as well as local knowledge of the patient - this is a significant advantage and value-add over traditional F2F review consultations which generally occur in isolation from the GP. New consultations, as a consultant Cardiologist, are much more difficult under current technologies, to do well by VC, with significant risks of wrong or missed diagnosis. For me, based on Covid19 experience, telephone consultation is no better than a chance ‘social’ encounter with the patient in the street or local supermarket, but I do understand that such a modality in GP can be used valuably in certain circumstances even if video consultation would be better. The limitation for direct video consultation to the patient, mostly in the home, as would occur in GP is patient, and, to some extent, GP familiarity with video consultation applications and hardware.
It has taken me and my practice staff more than 8 years and experience with many different VC platforms and services, and a lot of liaison with our GP practices, to now have VC as a fully integrated and highly valuable part of my rural consulting practice. It has increased my consulting capacity by 40% and enabled routine timely follow up of patients possible, where this was previously very difficult to achieve. Medicare funding for VC including the item number for both ends and current incentive payments should be retained, but only where the specialist is also providing F2F consultation and other services to that community - it is all about extending and adding value to, rather than supplanting, existing F2F services.
+1 # Anton Cush 2020-09-02 08:27
The feds came out initially promoting POTS during press conferences. Telehealth in primary care, mental health has always been referred to as phone until very recently at the gov level so no surprises really. Once the PMSs launch video platforms and some Medicare stipulations change there will be a shift but it will come from patient demand. Most GPs aren't that interested in changing from the traditional model.
0 # Janine Cox 2020-09-02 08:44
I great article thank you. I am current researching this exact topic for our Primary Health Networks region. The MBS utilisation data clearly shows the use of phone of video so as an organisation that can support workforce and adoption we need to understand some of the barriers for health providers and work to build confidence in the use of video. Incorporating a module on digital health may be a great way to embed the learnings early as well.
0 # Ellias Appel 2020-09-02 11:36
As a provider of interpreter services, we have been involved in telehealth at a hospital-level for a while. So it's been interesting observing what's been happening at a GP/clinic level, especially when TIS refused until very recently to consider telehealth a serviceable channel:
https://www.tisnational.gov.au/en/About-TIS-National/News/Telehealth-video-interpreting-for-medical-consultations-is-available-now

I'd be very interested to understand the barriers to adoption by GPs from a hardware and integration standpoint. Certainly, the specialists that I've spoken with managed it for exactly the reason described: they have their own hardware. So adding in an iPad (for example) to handle the video aspect leaves their main computer free to deal with patient records. I'd imagine it's a big barrier for GPs using a single screen setup (laptop or desktop) to easily integrate telehealth into practice while also accessing their main software platform.
0 # Andrew 2020-09-02 12:25
TIS is now providing an video interpreting service.
https://www.tisnational.gov.au/en/About-TIS-National/News/Telehealth-video-interpreting-for-medical-consultations-is-available-now
https://www.tisnational.gov.au/en/Agencies/Frequently-Asked-Questions-for-agencies

I wonder if interpretation by video would be preferable to interpretation by phone (that is, 3 way phone conference call)? I haven't tried either, yet. Anyone?
0 # Jane Connolly 2020-09-02 14:26
The Australian College of Rural and Remote Medicine provides telehealth resources to Members and non-Members www.acrrm.org.au/telehealth . This includes an online education module, telehealth standards, factsheets, use case videos and a national telehealth provider directory. Some of these resources are in the process of being updated and have been available since 2012 when Medicare telehealth item numbers were introduced. The College has many examples of video consultations used in clinical practice, 'GP with Patient and Specialist' 'GP to Patient in a private healthcare setting' 'Drs working for niche healthcare organisations like RFDS, Antarctic Division, Remote visiting services'. Context is key to what works best. If there are gaps in education, training and support tools we'd love to get your feedback at ehealth@acrrm.org.au
0 # Andrew 2020-09-02 15:13
Thank you very much, Jane, I did allude to the ACRRM guidelines in the summary. The ACRRM and RACGP guides are excellent. They provide practical advice on the approach to video consultations and on the implementation of video consultations in clinical practice. Some of the resources are only available to ACRRM members? (I'm a member).

Do you have any videos with simulated video consultations for educational purposes?

Does ACRRM run any courses for training/upskil ling in video consultations?
0 # Jane Connolly 2020-09-03 14:09
Thanks Andrew - I will be in touch to discuss the education ideas further.
All the ACRRM telehealth content is available to everyone. Everything you need can be found at www.acrrm.org.au/telehealth.
Some of it does require a login to the eHealth website but anyone can create an account (not just members). The videos we have are all hosted on the ACRRM YouTube channel and provide fly on the wall views of 'real' telehealth consultations. Then we have our online education course which has been replicated by RACP, RACS and NACCHO with our support.
Digital Health is part of the Colleges Curriculum which enables skills to be taught and practiced and this year were looking at improvements in assessment which you might be interested in.
0 # Andrew 2020-09-04 07:47
Thank you very much, Jane, I am very interested. Please contact me about this, as I would really like to get more information. I am a FACRRM. My email address is bairdak@gmail.com
0 # Anton Cush 2020-09-04 09:36
Jane, Hi again, nice to run into you here. Are these courses you outline here CPD-accredited? Best, Anton
0 # Andrew 2020-09-04 21:36
Logitech C922 webcam now available online at JB HiFi - at $189. It's $289 at Harris Technology ...
0 # Tony 2020-09-18 15:22
In reference to webcam Apple has everything built into their system I change years ago no add ons just one laptop .

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