THE role of a medical team is critical in all phases of a disaster management response. Beyond the immediate response phase of attending to physical safety with evacuation and stabilisation in severe life-threatening injury, there are needs for increased medical care in the immediate aftermath, particularly from the effects of smoke and other toxic compounds on the respiratory health of firefighters and the public.
The sequelae of exposure to smoke and fine particles (here and here) in smoke are significant and can be readily monitored in many parts of the country now. This monitoring of air quality, the health outcomes of poor air quality and the attendant obligations (here, here and here) are widely accessible.
A need to act has been recognised with the issuing of personal protective masks.
During the recovery phase, routine medical problems also need attention, with provision of adequate medication and monitoring in environments where services are still re-establishing themselves. Mental health effects of exposure to a traumatic event can also become more apparent or sustained for years to come. The health burdens of a disaster event are accentuated in vulnerable populations such as the frail and elderly or the very young; people already unwell, particularly with respiratory, cardiovascular or mental illness; or the immunocompromised. The disease burden will increase as a direct effect of poor air quality. The influx of visitors to some areas in the recovery phase is an increased source of additional potential health care burden.
The role of primary care in addressing the aftermath response and in the recovery phase is therefore critical and ongoing. Yet local services may be overstretched due to having been affected by the disaster themselves with health issues and damage to clinical infrastructure.
The increased needs of the population and visitors may need additional support from services outside the community. This support will need to be continued while communities rebuild medical centres. Locums can be deployed rurally but perhaps not in enough numbers when the needs of many communities across the country, affected simultaneously by fire, need to be met. The government has established streamlined processes for potential medical recruits to these areas. A proactive and sustained approach to responding to crises and rebuilding afterwards has been canvassed (here and here).
The potential of video consultation
With the active participation and agreement of local practitioners, a coordinated scheme to support local medical care with video consultations could be an additional source of much needed primary care medical support. This can be achieved using video consultation technology.
Previous experience in the Victorian Bushfire disaster of 2009 revealed that tele-mental health services experienced increased access by consumers to crisis counselling but less so for call-back services due to limited access to services. The recommendations were to integrate tele-mental health services into mainstream services and disaster response structures. Tele-health for other conditions is also being tested in other settings, including tele-psychiatry, across Australia, some distance administration of chemotherapy (Queensland) and specialist support in the Northern Territory in rural hospitals from teaching centres.
The last time video consultation was introduced as a Medicare Benefits Schedule (MBS) item in 2010–2011, its take-up was suboptimal and then largely discontinued. However, it means that we do not need to start from scratch to redevelop it.
As a result of these experiences, we suggest the service requirements below to enhance the feasibility of video consultation in a disaster recovery situation and which limit the Commonwealth’s liability.
A coordination centre in each jurisdiction, with trusted leadership and membership of key stakeholders, would be critical to ensure appropriate responses to emergent issues, codesign with local health services, and integration with routine local primary care, post-hospital care and other responses. A detailed assessment of each state’s needs would be an important first step in the response plan.
Stepwise levels of intervention might include:
- recruitment of local GPs to locum in areas of need;
- locums to work in larger regional centres;
- any Australian GP assisting using video consultation from their home base.
Review collaboration on the ground
Reading some of the posts about on-the-ground issues in the GPs Down Under Community of Practice, the Emergency Services response coordinators not allowing GPs to use initiative to provide services to their community in the bushfire response and recovery has caused offence to our GP colleagues, who feel their skills and potential contribution are being overlooked.
The Victorian State disaster plan (DISPLAN) and Emergency Management Victoria have always excluded GPs. GPs have not been seen as part of the solution and were never consulted in the response or design. There is a real opportunity to harness the valuable skills of a comprehensive primary care practitioner into a coordinated state system approach.
The unfortunate divide in funding sources for our health system, where general practice is funded through Medicare federally, ignores the fact that GPs work in the states where they live and are a crucial part of their communities. GPs have been meeting the health care needs of their communities before the fires and will also be doing so after – they have a vital role in responding to health care needs during the disasters also.
It’s important to stress that the discipline of general practice has capacity and a broad knowledge and skill base and is also accustomed to credentialing systems to ensure a high standard of care through the long-established Quality Accreditation process measuring practices against the Royal Australian College of GPs’ Standards for general practice.
Further, GPs have an electronic clinical information system with broadband internet access (previous Broadband for Health initiative) and are able to find details and put them in a central accessible format that is transmissible to My Health Record and other providers. To share this information will require use of secure messaging delivery, a capability that already exists and delivers all pathology and radiology reports to clinical information systems. To add outbound capacity is a minor change. Outbound capacity refers to sending messages out from GP clinical information systems to other providers’ systems as part of secure messaging delivery of electronic messages (a little like a secure email system).
My Health Record, secure messaging and the digital divide
GPs also are key participants in the MyHR, which might actually have an opportunity to show some benefit in this circumstance, where a GP external to the patient’s usual team is providing video consultation services. Even though 10% of the population have opted out of MyHR, the other 90% have a functional MyHR that can be used instantaneously.
Most health professionals with a clinical information system receive pathology and radiology results by secure messaging. Outbound classic secure messaging delivery is a small modification to existing systems but will have enormous and lasting benefits that will be in place for any future similar events.
Notwithstanding the potential benefits of video consultation, there is a digital divide in some areas of Australia and a current lack of infrastructure after disaster. However, solutions such as recent dropping of satellite phones into affected areas will enable the teleconference process. In other areas, mobile and National Broadband Network connections may exist as well as satellite ones.
How the video consultation would work
Re-introduce video consultation MBS items for a limited period of 12 months, thus ensuring the outlay is finite. If proven beneficial and cost effective, it can be retained easily. The past MBS items are available from 2010 — today’s MBS schedule is very restrictive for teleconsultations. We note that a recent announcement flags 24 months for teleconsultations for mental health.
Make video consultation items available to patients initially in disaster areas to access GPs (and possibly non-GP specialists) by video consultations immediately. They will be identified by the postcode where the patient is currently located. It need not be limited to disaster areas but where demand is too high to service. The load on GPs in rural and regional Australia is already high and this might be an opportunity to decant some of the workload so that they can cope better with cases to manage. However, we have to work with local practitioners because they are understandably protective of their patients and their commitment is lifelong.
Ensure that doctors who use the video consultation facility:
- have the ability to get accreditation;
- have a clinical information system;
- are connected to the My Health Record system;
- have the ability to send information by classic secure messaging;
- would use a web-based software and scheduling and workflow optimising software with confirmed confidentiality compliance that is easy to use; and
- are registered on the Health Direct website — funded by the Council of Australian Governments.
The expectation would be that a transcript or a synopsis of the consultation would be sent to both My Health Record and by secure message, with the patient’s permission, to the patient’s regular GP.
The government should pay a fee-for-service for the MBS component of the video consultation, which would be paid at out-of-hours rateThe government would pay for:
- software to all video consultations (which could start from tomorrow): installation, training and support from a list of preferred scheduling and workflow-optimising software. These scheduling and workflow solutions are available for free or through Health Direct and have been in use across Australia and in the UK; and
- standards-compliant, interoperable secure messaging for that 12-month period, which is part of the Australian Digital Health Agency plan.
When patients attend by video, they are identified using their first name, surname, date of birth and Medicare number, which can be put onto the clinical information system of the receiving doctor. The Medicare number will give access to their unique, national Individual Health Identifier, which has been in existence since 2010 (here and here), and their My Health Record. Privacy is assured. If the patient is not enrolled, they can be enrolled using the current existing portal in the clinical information system.
In a practice, reception staff and practice nurses can be part of the consultation workflow.
Using My Health Record, the most recent medications and consultations paid for by Medicare will be immediately available to help the consultation (this may require a tweak to the MyHR).
The scheme would be available right here, right now to reduce the load of local providers. It uses existing infrastructure. It will be much more useful in the intermediate period of recovery and, likely, in the long term consequences of severe respiratory, cardiovascular and mental health issues from these disasters.
The recent bushfire disaster will add to health care expenditure through increased health care needs. To achieve better health outcomes for the population in an efficient and timely way, health care must be accessible. While establishing a video consultation capability will require some expenditure, this may be offset by population health gains and health system efficiency.
Ideally, this process, along with a more integrated plan for involvement of GPs in disaster response, should be a coordinated effort in the national interest. It is essential to involve local providers, response teams and, for a broader plan for GPs to be integrated in response to future disasters, the Rural Doctors Association of Australia, the Australian College of Rural and Remote Medicine, the Primary Health Networks funded by the federal Department of Health, the Australian GP Alliance, the 8000 GPs who connect daily on GPs Down Under and, importantly, the Royal Australian College of General Practitioners and the Australian Medical Association. Consultation may well extend to involve other out-of-hospital providers such as medical and allied health specialists.
As in all new programs, academic expertise will be required to guide activity and evaluate outcomes of video consultations in disaster recovery. This expertise should be led by an academic department of general practice in collaboration with specific disaster response public health researchers who bring additional expertise and who may be assessing other public health responses. Academic departments of general practice, usually based in universities with medical schools, understand the nuances of the primary health care system and the way GPs work and combine this understanding with the academic rigour of program design and evaluation methodologies. Academic departments of general practice are networked nationally via the Australasian Association for Academic Primary Care.
Finally, this approach would have additional benefits such as use of a currently underutilised My Health Record system and it would enhance the classic secure messaging work the Australian Digital Health Agency needs to promote this year.
Working with coordination teams across the country, including first responders (eg, firefighters, police, ambulance, and the Australian Defence Force), the medical input and deployment will be invaluable.
Video consultation is a quick, efficacious and cost-effective mechanism to meet increased needs for health services in regional, rural and remote areas that are affected by today’s crisis and beyond.
Dr Mukesh Haikerwal AC is former President of the Australian Medical Association (2003–2005), past Chair of Council of the World Medical Association (2011–2015), Chair of Beyond Blue’s Doctors’ Mental Health Program, former Chair of the Australian Institute of Health and Welfare (2014–2016), former National Clinical Lead of the National eHealth Transition Authority, and former Commissioner of the National Health and Hospitals Reform Commission. He is principal of a general medical practice in Altona North in Melbourne.
Professor Lena Sanci is Head of Department and of the Children and Young People’s Research Stream in the Department of General Practice, at the University of Melbourne. She co-Chairs the Primary Care Committee of the Melbourne Academic Centre for Health and has expertise in the codesign of interventions, implementation, and evaluation in primary care and online settings. She chairs the Victorian Research and Education Network (VicREN) of over 600 general practices with a commitment to advance the discipline of primary care through teaching the next generation of health professionals, and through research.
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.