Introduction by Croakey: Around the world, health authorities are turning to telehealth as an important plank in responses to the novel coronavirus outbreak (see tweets at the bottom of this article).
In the United States, a $8 US billion emergency spending package includes funding to allow Medicare providers to extend telehealth services to seniors regardless of where they live, while the Centers for Disease Control and Prevention also includes telehealth as part of its recommended actions.
Meanwhile, medical groups have welcomed Australian Government plans to extend telehealth as part of its COVID-19 responses.
In the article below, University of Queensland researcher Dr Centaine Snoswell and colleagues urge governments and clinicians to embrace telehealth during this public health crisis, although they say it is not a panacea and there are some significant barriers to ensuring its widespread and equitable use.
Centaine Snoswell, Ateev Mehrotra, Emma Thomas, K-lynn Smith, Helen Haydon, Liam Caffery and Anthony Smith write:
Amid so many questions and concerns about Australia’s response to the novel coronavirus, there is some good news: the Australian Government is investigating how to enable wider use of telehealth and telephone triage services.
Pulse IT magazine reports that the Federal Health Department is consulting with medical groups about developing a specific MBS item number for GPs providing services to patients with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
We welcome this news: telehealth must be a critical component of the response from both the government and clinical community.
Telehealth is not a new concept – it has been around for decades. Telehealth is simply the process when a patient has an appointment with a healthcare provider using digital technology such as videoconferencing.
The benefits of telehealth have been well articulated; a recent Medical Journal of Australia article stated: “One of the drivers for telemedicine is to improve access to health services that would otherwise be unavailable, prohibitively expensive, inconvenient or impossible for patients and carers to use.”
In the case of SARS-COV-2 and the disease it causes, COVID-19, telehealth may reduce the likelihood of viral transmission by limiting person-to-person contact, while enabling patients with the virus to be treated for viral symptoms and their normal medical conditions.
The greatest benefit may not be to those patients with COVID-19, but to patients who need to access health services during the outbreak.
Up to 50 percent of GP visits are for the management of chronic disease. Given that health care needs of people with chronic illness will not change in the event of a pandemic, one can assume that at least half of all patients found in a waiting room have some form of chronic disease – and an even higher proportion are elderly.
Here lies another problem – our older population with a chronic disease are the most susceptible to COVID-19 infection.
We believe telehealth can play a critical role in this public health crisis.
Firstly, it can potentially reduce the spread of infection by reducing patient-to-patient contact. Telehealth may also decrease the risk of exposure for health care workers.
It can enable patients (especially those suspected COVID-19 cases and those on mandatory self-isolation) to access care without the potential of spreading the virus to others.
Secondly, it can assist with controlled triage of patients – pre-screening those who should be tested, and those who should receive care prior to bringing them to a facility or potentially enabling remote diagnosis.
Beyond the care for immediate symptoms, people who require ongoing access to care for their pre-existing conditions can access care without risk to themselves or others. Lastly, these efforts could also potentially help relieve the pressure on emergency departments, which are likely to be overwhelmed.
We support the Royal Australian College of General Practitioners request that the Australian government should relax current restrictions around the provision of telehealth services by removing geographical constraints and permitting GPs to interact with their patients irrespective of location.
This includes allowing all types of providers, such as general, nurse, allied health, and mental health practitioners, and all patients (not only those in remote areas) to use telemedicine.
This would not be an unprecedented response by the Government. In 2018 and then in 2019, additional telehealth services were funded for people affected by drought and bushfires (for example, additional mental health support services). Telehealth has also been used to help improve access in prior emergencies in the US – such as the hurricanes in 2018.
Patients, including those with COVID-19, suspected infection, and those worried about sharing a waiting room with people who may be infected should be encouraged to seek telehealth services – especially those who are isolated and in need of ongoing care.
Now is the time for patients and care providers to critically appraise the need for in-person appointments, and create protocols and frameworks so that they can be converted to video or phone visits.
If there is no reason for patients to be physically present for an appointment, and the patient can be safely and effectively managed at a distance, then there should be no question about the use of telehealth.
Care providers should embrace services such as remote monitoring to manage COVID-19 infected patients from a distance; and to provide services to patients in need of routine care from chronic conditions (for example, tracking blood pressure, and blood sugars).
Provision of high-quality patient-centred healthcare is a corner-stone of the Australian healthcare system and in 2020 telehealth is now ready to play a critical role to address this public health crisis.
Even if there was no pandemic looming, it is time to appreciate the value of telehealth and to ensure that new models of care include telehealth in a “business as usual” manner.
Since 2011, the Medicare Benefits Schedule (MBS) has included remuneration for a range of specialist medical consultations delivered by videoconference. These telehealth services are already widely used in rural and remote communities with over 150,000 visits in 2018.
The original impetus behind the MBS telehealth funding has been to improve access to specialist services for rural and remote patients.
Whilst this policy has considerable merit, the use of these items for patients in metropolitan areas (city locations) is not currently permitted; perhaps the COVID19 outbreak will be the impetus to change this policy going forward.
In 2018 there were approximately 21.6 million general practice visits and allowing many of these visits to occur via telehealth could improve access to healthcare, and slow transmission of COVID-19.
To participate in telehealth a patient needs access to videoconferencing platform and an Internet connection. Consumer videoconferencing platforms that run on a tablet computer or PC are now freely available and cheap. These platforms are suitable for telehealth and mean telehealth services can be provided directly into the patient’s home.
However, 1.3 million Australian households are not connected to the Internet, with disadvantaged groups making up the majority of these households. It is hard to know whether the ubiquitous use of smartphones would circumvent this.
Socio-technical reasons are like to account for the fact that Australians over 65 year olds are half as likely to use online health services compared to the national average. The irony is that in the advent of a pandemic these are the very people who are likely to need and benefit from telehealth.
Barriers to address
For telehealth to play a role in the pandemic and disaster response, a number of barriers need to be addressed. Many clinicians lack the ability or inclination to use telehealth. Research shows this is a major factor limiting uptake of telehealth.
Telehealth requires clinicians to learn new ways of consulting. For this reason improving telehealth literacy through education aimed at both undergraduate and post-graduate clinicians is needed to facilitate wider utilisation.
Nationwide there is very little telehealth content in medical school curricula and, because accrediting bodies do not expect digital health competencies in graduates, there is no pressure to include it.
Mandating accreditation may be necessary for clinicians to prioritise undertaking appropriate education to enable them to practise telehealth. Patient expectations around choice and convenience are likely in the future to help drive the uptake of telehealth.
However, improved consumer awareness of telehealth is necessary before this can happen.
Perhaps the greatest limitation is that not all health interactions can effectively be done by telehealth.
Patients will still need to attend health care facilities for procedures, imaging and where a physical examination such as auscultation is required. For this reason, telehealth is not a panacea to the delivery of health care during a pandemic.
- Dr Centaine L. Snoswell is a research fellow at the Centre for Health Services Research, The University of Queensland where she is examining how telehealth can make the Australian health system more sustainable for the NHMRC Partnership Centre for Health Systems Sustainability. Follow on Twitter at: @CSnoswell
- Dr Ateev Mehrotra is an Associate Professor at Harvard Medical School and under a Fulbright Scholarship studying the deployment of telehealth in Australia. Follow on Twitter at: @Ateevm
- Dr Emma Thomas is a research fellow and telehealth consultant within the Centre for Online Health, Centre for Health Services Research, The University of Queensland. Follow on Twitter at: @_emma_thomas
- Dr K-lynn Smith is a postdoctoral research fellow with the NHMRC Partnership Centre for Health Systems Sustainability.
- Dr Helen Haydon is a research fellow and telehealth consultant at the Centre for Online Health, Centre for Health Services Research, University of Queensland. Follow on Twitter at: @HelenHaydon
- Associate Professor Liam Caffery, is a principal research fellow within the Centre for Online Health, Centre for Health Services Research, The University of Queensland. Follow on Twitter at: @DrLiamCaffery
- Professor Anthony Smith, is the Director of the Centre for Online Health, Centre for Health Services Research, at The University of Queensland; and Editor-in-Chief of the Journal of Telemedicine and Telecare.
Declaration: All authors conduct research in the use of telehealth or health system sustainability. None have any financial interest in any telehealth vendors or providers.
In the United States
This article mentions the potential for telehealth to help manage mental health and wellbeing during extended periods of isolation and quarantine.