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

NSW VIC QLD SA WA TAS ACT NT Total
2011 1123 429 1804 195 841 142 8 40 4582
2012 9860 5711 10 587 2666 3634 1387 124 334 34 303
2013 16 580 8655 17 513 3815 3491 2920 130 769 53 873
2014 23 093 12 567 26 375 6032 4522 4967 193 1440 79 189
2015 28 636 15 316 31 304 5887 5111 4878 258 1560 92 950
2016 30 469 20 476 35 782 6424 6135 5066 368 2049 106 769
2017 34 700 24 068 39 530 6394 7075 5358 280 2866 120 271
2018 43 550 28 004 47 453 7192 7999 7087 395 3123 144 803
2019 55 802 39 084 57 814 9015 9677 8362 463 3472 183 689
Total 243 813 154 310 268,162 47 620 48 485 40 167 2219 15 653 820 429

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.


Poll

I will use telehealth more often as part of my regular practice once the pandemic is over
  • Strongly agree (52%, 62 Votes)
  • Agree (22%, 26 Votes)
  • Neutral (11%, 13 Votes)
  • Disagree (8%, 10 Votes)
  • Strongly disagree (7%, 8 Votes)

Total Voters: 119

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6 thoughts on “COVID-19 consequence: telehealth will go mainstream

  1. Anonymous says:

    Absolutely agree Peter Bradley!
    Telehealth consults are very much appreciated and useful for many patients but bulk billing wont pay for GPs to stay in business providing good GP care in a private business model.
    I have worked in New Zealand and the part capitation and part private fee model works well and patients also register with a specific GPs practice which promotes better continuity of care and wastes less resources ,as the patient doesnt use multiple GPs and therefore wastes less radiology and laboratory resources from multiple GPs .
    A good GP is equivalent to a specialist and should be paid an equivalent amount either as a salary or private specialist gap fees

  2. Anonymous says:

    Whilst as a respiratory specialist I support telehealth and have been using it not only during the COVID-19 pandemic but for rural patients prior to this as well. I am concerned about the way bulk-billing is being forced for the majority of patients seen (most people fall into one of the vulnerable categories). I also think clinical examination is important for many patients at review so this needs to be considered. But perhaps most importantly patients need to have choice – I have offered either face to face – with protections such as waiting in the car until appointment, appropriate social distancing in waiting rooms etc. About 3/4 of my patients actually prefer a face to face consultation – so lets make sure there is ongoing choice for all.

  3. Toulouse Letrack says:

    Fellows:

    Two new and distinct issues have emerged, and I think they are very relevant to Telehealth and the Privacy Legislation:

    1
    ZOOM is commonly used for Tele-health… but it is not yet fit for purpose. It has security flaws, and can easily be hacked:

    Read about it here:

    https://www.bbc.com/news/technology-52133349

    https://www.theguardian.com/technology/2020/apr/02/zoom-technology-security-coronavirus-video-conferencing

    https://www.cnet.com/news/zoom-every-security-issue-uncovered-in-the-video-chat-app/

    There are workarounds, but I prefer to use WhatsApp, which is encrypted, and can flip between phone and video easily.

    2.
    BGP: Border Gateway Control is the postal service of the Internet. It’s responsible for looking at all of the available paths that data could travel and picking the best route. (Sorry about the tech language below.)

    By default, BGP does not embed any security protocols.
    A practice called BGP hijack consists of redirecting traffic to another autonomous system to steal information (via phishing, or passive listening for instance).

    BGP is largely not secure; there is a way to make it secure.
    BGP route validation is needed. Filters need to be built in order to make sure only legitimate routes are accepted.

    BGP route validation can be achieved by a mature implementation called RPKI.
    RPKI uses cryptography to provide nodes with a way of doing this validation.

    Internet Service Providers need to implement this certification system called RPKI.

    For BGP to be safe, all of the major ISPs will need to embrace RPKI.

    You can test whether your existing ISP has implemented BGP route validation using a test on this page:

    https://isbgpsafeyet.com

    This second issue needs a statutory response, and an urgent one, too.
    (Your messages and sent files can be routing through Russian Dark Web nodes used for criminal activity.)

  4. Anonymous says:

    Can you please let me know whether you used these MBS Item numbers for the compilation of this data?

    99, 112, 113, 114, 149, 288, 384, 389, 2799, 2820, 3003, 3015, 6004, 6016, 13210, 16399, 17609, 2100, 2126, 2143, 2195, 2122, 2137, 2147, 2199, 2125, 2138, 2179, 2220, 10983, 10984, 82150, 82151, 82152, 82220, 82221, 82222, 82223, 82224, 82225.
    And also whether they relate to services for the calendar year from Jan to Dec?

  5. Anonymous says:

    I am interested in clarifying the legislative basis whereunder government can mandate bulkbilling of ANY patient category.

    The Medicare rebate is insurance for the patient , to defray their medical costs.

    Does a state of emergency allow this precedent -is it legislative, or a political gambit moving towards an endgame of nationalization ?

    We need to be alert to the taking advantage of our professional philantrophy in the interest of control.

  6. Peter Bradley says:

    Notwithstanding the probable truth of the final sentence above… “However, I believe that irrespective of the duration of this pandemic, one of the lasting consequences will be that telehealth consultations will become mainstream.”
    …whichever way you look at it, this pandemic has in some ways been the last straw, so to speak, in demonstrating just how way past its ‘use by’ date, the current item-based fee for service model of funding primary care is, and there has to be a huge re-think about this. Even with telehealth, the drop off in face to face presentations, and claimable telehealth services, especially as you may as well say, the rebate is the fee for everybody, as so few fall outside the span of those categorised as ‘must be bulk-billed, that financially practises are going to start closing, and may never be re-opened.

    To salvage the situation, it appears funding can only go down two paths. Copy to some extent the capitation model, with generous bulk-funding of practises, and probably allow for a discretionary FFS as well, as in the NZ model. Certainly not the completely free UK model..! The ‘medical home’ model already mooted has huge issues as well’

    Or – and I have always favoured this model – set GP up as a fully govt funded public service type salaried service, but with a discretionary up front user pays fee – which goes not only towards costs, but discourages over-use and abuse of the service. There are other benefits of this alternative over and above the financial security and flexibility it provides. A proper career pathway, with recognition of extra qualifications and seniority, etc, for example. I personally don’t see any other way working, and though now retired, nothing has changed this view in over 45 years of GP, and in two countries.

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