COVID-19 consequence: telehealth will go mainstream

AS of Sunday 19 April, Australia has 6606 confirmed cases of coronavirus disease 2019 (COVID-19) and 71 deaths as a result. People with chronic illness, in particular those with diabetes, and the elderly, may be at greater risk.

Suppression strategies – the rapid adoption of public health measures, including testing and isolation of cases and wider social distancing measures (here and here), to suppress transmission – are currently favoured to flatten the demand curve for critical care resources. The introduction of new COVID-19 telehealth Medicare item numbers provides an opportunity to optimise these suppression strategies while maintaining access, continuity of care, and health protection.

By allowing communication and collaboration remotely and at distance, digital technology is playing a major part in many industries in balancing the dual objectives of social distancing and preservation of economic activity while facilitating the overarching suppression strategy. Similarly, in the health care setting, these technologies are key and central to the prompt adoption of suppression strategies. Moreover, in health, in addition to being able to allow business to be conducted as usual, they offer the additional role of health protection to both the carer and the practitioner, given that both groups are at higher risk of contracting infection. They ensure people can access essential care in a way that reduces their potential exposure to infection while maintaining continuity of care. They also mitigate the risk of key health care workers who are at the frontline of this pandemic infection.

In the current Australian environment, it was heartening therefore to see the expansion of telehealth consultations as one of the first initiatives of the Commonwealth government. Although telehealth consultations were introduced in 2011, these were limited to videoconferencing attendances for those living more than 15 km from the practice. As shown in Table 1, the uptake of these technologies has been relatively slow over the past 10 years, despite generous incentives and progress in technology capabilities (improved videoconferencing technology, cloud computing and mobile telephone platforms).

Table 1:

Total number of Telehealth Consultations (2011–2019) by states and territories of Australia

Source: http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp

These technologies include the use of various communication platforms, both formal and funded (telehealth attendances, telephone and videoconferencing) and informal and not funded (SMS, WhatsApp messaging, Facebook Messenger) that may or may not be linked to the existing platforms for electronic medical records (EMR) and electronic health records (EHR).

The Commonwealth government’s announcement of these item numbers has extended this technology for GPs, specialists, consultant physicians, obstetricians, consultant psychiatrists, nurse practitioners, allied mental health workers and midwives to include not only videoconferencing but also telephone attendances and has removed the geographic restriction for vulnerable or isolated patients.

All Medicare-eligible Australians can now receive these services as of 6 April 2020. All services provided using the Medicare Benefits Schedule telehealth items must be bulk-billed for Commonwealth concession card holders, children under 16 years of age, and patients who are more vulnerable to COVID-19. For all other patients, bulk billing is at the discretion of the provider, so long as informed financial consent is obtained prior to the provision of the service. Vulnerable means:

• the person has been diagnosed with COVID-19 virus but is not a patient of a hospital; or
• the person has been required to isolate themselves in quarantine in accordance with home isolation guidance issued by Australian Health Protection Principal Committee (AHPPC); or
• the person is considered more susceptible to the COVID-19 virus being a person who is:

1. at least 70 years old; or
2. at least 50 years old and is of Aboriginal or Torres Strait Islander descent; or
3. is pregnant; or
4. is a parent of a child under 12 months; or
5. is already under treatment for chronic health conditions or is immunocompromised; or

• the person meets the current national triage protocol criteria for suspected COVID-19 infection.

The services will be available until 30 September 2020. The continuing availability of these items will be reviewed before 30 September.

Other countries, including the UK, have also started to apply telehealth technology for the diagnosis and treatment of COVID-19.

Since the announcements, data in our practice group (unpublished), which includes 160 specialists across New South Wales, Queensland and the Australian Capital Territory, indicate that more than 50% (847/1663) of all follow-up consultations in the first week are now using the COVID-19 item numbers.

In my particular specialty of diabetes and endocrinology, people with diabetes and metabolic syndrome appear to be at increased risk of complications from COVID-19 (here and here). As a consequence, the COVID-19 Medicare item numbers have facilitated a rapid transformation of clinical practice. New patient consultations are seen face-to-face, unless they fall into the vulnerable COVID categories a, b or d. New patients who are unable to attend in category c may also be assessed by telehealth.

Virtually, all our follow-up consultations are now being undertaken as a telehealth consultation. The history is taken, the physical examination is limited, although many aspects can be assessed remotely. Physical appearance is easy with videoconsultation.

There are multiple methods to collect pulse rate using consumer available devices (eg, Fitbit, Android systems, Apple Watch to name a few) as well as medical devices that can monitor cardiac rate and rhythm continuously. New technologies using digital skin patches promise the ability to monitor a range of clinical and non-clinical parameters. Remote auscultation is also technically feasible though not generally available. Palpation is not yet available, although telehaptics is being developed. There are a range of analogue and digital technologies for reporting of biochemical measures. For example, all biochemical results are directly available either via the doctors’ EMR or through My Health Record. I often use mobile phone apps to search for results and then share these directly with the patient or by snapshotting a photo of the screen and sending them electronically by SMS or by email to the patient.

Blood glucose monitoring is one of the key planks for patients with type 1 diabetes as well as for high risk patients with type 2 diabetes. Most blood glucose monitors can now be uploaded to a central cloud system and interrogated by both practitioner and patient. These systems allow for almost real-time adjustment to treatment protocols and decision making (here and here). If this technology is not available, then I often use a hybrid solution of an old-fashioned diabetes record book that is photographed and sent by email or SMS. This is then followed by a video or telephone call. The collection of all information is then captured into an EMR and then may be uploaded to the EHR, My Health Record. Correspondence is captured by digital recording using a phone app and transcribed in the cloud and returned seamlessly to my EMR and phone.

Parenthetically, the rapid adoption of telehealth has been promptly accepted by patients. This safety net provides them with a degree of confidence and comfort as well as reducing unnecessary attendances to the consulting rooms or to the emergency room. They appreciate being able to make contact with their practitioner rapidly when required. Many of my vulnerable and complex patients who have my email and mobile contacts will directly message or email me when major concerns arise.

Although many of us have been using these technologies for years, the introduction of the new COVID-19 Medicare item numbers makes these activities sustainable as part of routine practice. Future studies will assess the impact of these COVID-19 item numbers on uptake and outcomes. There are many details to be sorted out, including extending these numbers to other practitioners, as well as the level of rebate. Australia has led the way in this particular aspect of the response to the COVID-19 strategy to assist in “flattening the curve”. There are many steps that will need to be taken going forward before life returns to normal.

However, I believe that irrespective of the duration of this pandemic, one of the lasting consequences will be that telehealth consultations will become mainstream.

Steven C. Boyages is Clinical Professor with the Sydney Medical School at the University of Sydney, and Westmead Clinical School.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.