Joining the docs

Annabel McGilvray
Med J Aust
Published online: 17 June 2013

Telehealth is beginning to gather momentum in private practice. How are those already connected making it work?

On some days, Dr Ewen McPhee’s clinic in the outback town of Emerald, Queensland, is more akin to a broadcast studio than a general practice.

On those days — roughly once a week — as many as 15 videoconferences take place between Dr McPhee’s Central Queensland patients and their far-flung specialists.

The first take may be the regular paediatric telehealth clinic, when three or four children and their families speak with paediatrician Dr Michael Williams, who is based more than three hours’ drive away in Mackay.

Afterwards, one of the practice’s registrars may sit in for the pre- or post-op assessments via Skype with a Brisbane-based plastic surgeon.

Or Dr McPhee may pop his head in to provide further community information or medical details for a specialist in any one of 24 other fields the practice liaises with online.

Dr McPhee estimates that they have facilitated as many as 200 such consultations within the past 12 months.

“Everyone seems very comfortable with it and especially when they realise they’re not going to have to fly to Brisbane for a three-minute consult and then come back again”, he says.

The telehealth numbers at McPhee Medical Group are at the very high end, but Dr McPhee is just one of an increasing number of doctors around the country who are beginning to take advantage of the technologies and initiatives encompassed by the term “telehealth”, to try and improve the access to care for patients in rural and remote areas, Indigenous Australians and those in aged care.

Billing for Medicare Benefits Schedule (MBS) telehealth services by general practitioners more than doubled in the last year.

The absolute numbers are still not large — 5379 GP-facilitated videoconferences around the country between January and March this year, up from 2268 the year before — but this is starting from zero when the MBS telehealth item numbers were first introduced on 1 July 2011.

The Royal Australian College of General Practitioners recently called for the telehealth services covered by the MBS to be significantly expanded to include patient-to-GP telehealth consultations in addition to the GP-facilitated patient-to-specialist services already listed.

The Australian College of Rural and Remote Medicine’s (ACRRM) Telehealth Provider Directory now lists 525 general practice telehealth providers from Queensland’s Charters Towers to Western Australia’s Carnarvon.

For many, videoconferencing has been a new addition to older telehealth programs such as the ACRRM-run Telederm program, which provides a store-and-forward service for dermatology advice and education.

The value of these services was demonstrated recently when concern about a delay in the 2013 funding for Telederm sparked a vigorous social media response from rural GPs.

There was a rash of blog posts and tweets from IT-savvy GPs working in the remote reaches of Australia before, late last month, the Minster for Health Tanya Plibersek announced funding would continue.

In a field where the biggest factor governing cost-effectiveness is volume, the numbers are important.

When the government introduced the $620 million telehealth program in the 2010 Budget, they planned to fund more than 495 000 consults by July 2015.

At the end of March this year — two years from the government deadline — just over 80 000 consults had occurred, and this allows for double counting the consultations in which both specialists and either GPs or Indigenous health workers and nurse practitioners took part.

The figures are moving in the right direction, but the movement is slow for a number of reasons.

Among those set up to offer telehealth, the use and capacity vary enormously.

While Dr McPhee has a high number of telehealth consults, others, such as Dr Tim Leeuwenburg, practising on South Australia’s Kangaroo Island, carry out as few as just two videoconferences a month.

Dr Leeuwenburg used the original $6000 Telehealth Onboard Incentive payment to acquire the audiovisual hardware and software required, but says one of the problems has been that many of the specialists he refers to — in particular those in the South Australian public hospital system — don’t have compatible technology.

“The technology is a bit of a white elephant”, he says. “It’s very hard to do unless it’s a follow-up appointment with somebody who is already in the private system.”

Interoperability and connectivity remain a problem for everyone.

Without any coordination, different specialists have different IT systems requiring GPs to have different software for effective videoconferencing.

Because of this, and despite the generous onboard incentive payments, according to a recent ACRRM sample, the vast majority of telehealth consultations (88%) take place on Skype.

By their nature, such consultations are limited to the head and shoulders view and so while ideal for psychiatry, they are unsuitable for patients requiring any form of examination.

Many doctors, such as Dr McPhee, have had to install a range of different software in order to communicate with the public system and different operators in the private realm.

Even if software compatibility problems can be overcome, the potential for telehealth to play a larger role in general practice is being sabotaged by problems with internet connectivity.

In this regard, the National Broadband Network comes in for particularly sharp criticism.

For those on the ground trying to implement telehealth, the fibre connections appear to be going to all the wrong places, bypassing aged care homes and medical centres.

It means that the cost of trying to ensure a secure connection — whether in outer Melbourne or Central Queensland — is significant and ongoing.

Those following telehealth, such as Dr Victoria Wade, a GP completing a PhD on its sustainability at the University of Adelaide, say these handicaps continue to prevent it from becoming a regular part of general practice and mean it is likely to take a much longer time to prove its cost-effectiveness.

“It’s still very low volume. So because it’s not fully integrated into routine practice, it’s still taking extra time”, Dr Wade says.

“Despite the extra 30% telehealth service fee and the incentive payment, many GPs are looking at it and saying it still doesn’t add up.”

She says this is unlikely to be helped when the extra service incentive payments are reduced from $32 to $26 per consultation and the onboard incentive funding drops from $3200 to $2900 on 1 July this year, with incentives to end altogether on 1 July 2014.

Both Dr McPhee and Dr Leeuwenburg say the cuts will make it necessary for them to reconsider their commitment to telehealth.

Neither is confident that patients will be willing or able to bear an increased co-payment, despite the savings in travel, time and accommodation it offers.

But Vicki Sheedy, ACRRM strategic programs manager for eHealth, is more optimistic.

It’s still in its infancy, she says, and can only make better business sense as better models of care are created.

“We see it still in its developmental stages. We think there’s a lot of room for improvement. There’s a lot of room for new models of care to emerge from it.”

To that end, the College is now looking to work with specialists who are visiting rural communities, to see how telehealth can be used to optimise care between, during and after visits.

“To look at what really constitutes shared care using telehealth as a medium … that’s something we want to explore with other colleges, with our members and other telehealth users”, Ms Sheedy says.

Meanwhile, on the morning we spoke, 20 000 feet above the South Australian coast Dr Leeuwenburg had encountered a patient on the same flight as he was taking to Adelaide.

The patient was flying to the mainland for a consultation with a specialist who, much to Dr Leeuwenburg’s dismay, was still not equipped for telehealth.

“[The patient] knows that he’s probably going to spend 10 minutes with that specialist”, says Dr Leeuwenburg. “He will also have to pay for his airfare and taxi.”

“Using telemedicine would probably have saved him lots of money and a nine-hour journey there and back!”

  • Annabel McGilvray



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