GPs have a major role in managing most people with coronavirus disease 2019 (COVID-19). They also have a major role in managing people who have the epiphenomena of COVID-19: psychosocial distress, adjustment difficulties, and mental illness. Video consultations are appropriate for managing these people.
Although the media focus is on people who are hospitalised with COVID-19 and on people who have died of COVID-19, most people who have the virus are in the community for the duration of their illness; they self-manage their illness at home.
Through the COVID-19 pandemic, and in the aftermath, GPs have an ongoing role in providing comprehensive, continuing care to their patients, their patients’ families and their patients’ communities. This includes providing acute care, chronic disease management, and preventive activities. Telehealth will have an ongoing role in many facets of patient care in general practice.
And yet Medicare data for the months of May and June 2020 tell us that video consultations are not being taken up in the numbers we might expect. The data show that for non-face-to-face attendances by GPs at levels B, C and D, 97% were by phone and just 3% were by video.
In Medicare terminology, “telehealth” is a non-face-to-face service by video. Non-face-to-face services by phone are described as “phone services”. There are separate Medicare Benefits Schedule (MBS) item numbers for video services and for phone services.
Video consultations are virtual face-to-face consultations. To reduce ambiguity, the term “in-person” could be used in lieu of “face-to-face” for consultations where patient and doctor are present in the same room.
“Videoconference services are the preferred approach for substituting a face-to-face consultation. However, in response to the COVID-19 pandemic, providers will also be able to offer audio-only services via telephone if video is not available.”
It appears that based on above data, video has been “not available” for 97% of non-in-person GP attendances at levels B, C and D, but Medicare does not define “not available”.
Is it likely that video has been “not available” in such a high proportion of non-in-person consultations? Or have GPs been generous in their interpretation of “not available”?
The following questions need to be addressed:
- What are GPs’ definitions of “video is not available”?
- Are GPs using the phone for consultations when, for the purposes of Medicare benefits, they should be using video?
- What are the barriers:
- to the availability of video?
- to the use of video for non-in-person consultations?
To date, there have been no surveys to answer these and other questions about the use of video for consultations in general practice; however, some possible barriers for GPs and patients are listed below.
Potential barriers for GPs’ use of video for consultations
- Negative attitudes to video;
- unfamiliarity with video;
- perception that the time taken to set up a video consultation will encroach on the time available to attend to the patient;
- interruption and/or disruption to workflows in the clinic;
- low competence and/or low confidence with the technology, equipment, and software;
- “it’s easier to pick up the phone”;
- “patient not ready for the consultation when the GP connects the video call”;
- availability and cost of equipment (computer, webcam, microphone, speakers, headset, internet with speed at least 300 kbps);
- concerns about so-called pop-up or on-demand telehealth services.
Barriers to the patient’s use of video for consultations
- Negative attitudes to video;
- preference for phone;
- GP does not provide and/or advocate the use of video for consultations;
- lack of familiarity, competence, and/or confidence with technology (eg, elderly persons, culturally and linguistically diverse persons, vision or hearing-impaired persons);
- availability/cost of equipment (phone, computer, webcam, microphone, headset, internet access etc) — these issues may be a problem particularly for culturally and linguistically diverse persons, First Nations’ people, people living in socio-economically deprived areas, and homeless people;
- “GP running late” — patients do not like sitting at their computer and waiting.
The benefits of video consultations
Video is a relatively new phenomenon for Australian GPs and patients, and represents a new paradigm in GP–patient communication.
Before the COVID-19 pandemic, temporary MBS telehealth item numbers were introduced on 13 March 2020, only pop-up, and a minuscule but unknown number of telehealth services in traditional general practices were available. These consultations were not eligible for a Medicare benefit.
In many instances, a video consultation has advantages over an in-person consultation.
Video consultations enable a remote connection between GP and patient, with audio and video. Rapport, indirect physical examination, and mental state examination are enabled. The GP’s and the patient’s facial expressions, gestures and body language can be observed and interpreted. Cueing dialogue is easier when GP and patient can see one another (that is “whose turn is it to speak?”).
Patients can also send photos and files to the GP, securely and encrypted, through the video link, and GPs can similarly send the following to the patient: photos, files, referrals, investigation requests, patient instructions and patient information. However, prescriptions should not be sent to patients electronically; they can be sent to pharmacies by email (if ePrescribing is not available).
Although video cannot be the default mode of consultation in general practice, it can be considered as an alternative to any in-person consultation that does not require direct physical examination.
A review prepared by Trisha Greenhalgh, on behalf of the Interdisciplinary Research in Health Sciences group at the University of Oxford, has found that video consultations are safe for low risk patients. The review indicates that compared with in-person consultations, video consultations are similar in clinical outcomes, associated with high levels of patient and clinician satisfaction, and modest cost savings. However, there is limited research on the use of video consultations in general practice or in pandemic situations. There is no evidence for outcomes in population health.
It is likely that uptake of video will increase with time and familiarity. Specialists have been using telehealth since Medicare introduced specialist telehealth item numbers in 2011, and based on May 2020 data, 16% of specialist COVID-19 non-in-person attendance item numbers were for video, compared with 3% for GPs.
Other potential benefits of video consultations include:
- increased income and decreased costs for GPs;
- consultations are low cost or free for patients (if bulk-billed);
- not necessary to travel (for patient to clinic; for GP to home visit, aged care facility);
- no need to sit in waiting room;
- time not wasted on travel or waiting;
- no costs for travel and parking;
- no infection risk; no requirement for personal protective equipment;
- GP and patient do not need to wear face masks (can see full face);
- virtual home visit.
COVID-19, GPs and video consultation
There is an opportunity for GPs to proactively provide support, assessment, management and monitoring for patients with COVID-19 who are at home.
Video consultations are appropriate for this purpose. Telehealth (video) services will be bulk-billed at level B, C or D (items 91800, 91801 and 91802 respectively). The COVID-19 bulk-billing incentives will apply to these services (items 10981 or 10982).
This is particularly relevant for the current situation in Victoria, where, as at 11 August 2020, there were 15 251 cases of diagnosed COVID-19 (total), 7880 active cases of diagnosed COVID-19, and 246 deaths caused by COVID-19. There have been over 2500 new cases of diagnosed COVID-19 per week over the 3 weeks to 3 August 2020.
All patients who are in a stage 3 or stage 4 lockdown area are eligible for Medicare benefits for the telehealth (video) item numbers, as they are exempt from the “patient’s usual medical practitioner” requirement.
While we know GPs are already having telehealth consultations with patients who have COVID-19, it is not known what proportion of patients with COVID-19 at home are having telehealth consultations with their GP during their illness, and it is not known what proportion of these telehealth services are by video or phone.
Advice for COVID-19 video consultations
In an editorial and a “10-minute consultation” published in the BMJ in March 2020, Trisha Greenhalgh and colleagues describe approaches to the video consultation in general practice, with a particular focus on video consultations for patients with COVID-19. They include an infographic for COVID-19 remote consultations.
At such a video consultation, for either patients with diagnosed COVID-19 or for patients with presumptive COVID-19 (symptomatic patients who are waiting for their COVID-19 test result), a GP can:
- support for the patient’s mental wellbeing;
- advice on management (fluid intake, paracetamol, etc)
- monitor – history:
- isolation (is the patient staying at home?);
- symptoms and the trajectory of symptoms (improving, stable, or more severe?)
- monitor – indirect physical examination:
- mental state (drowsiness, confusion?);
- temperature (if the patient has a thermometer);
- pulse rate (GP can demonstrate via video how to check the pulse; GP can time the pulse rate);
- blood pressure (if the patient has a blood pressure monitor);
- respiratory rate (ask the patient to place their hand on their chest; GP can time the respiratory rate by counting movement of the hand);
- work of breathing (talking; the patient can remove their upper clothing so that the GP can observe respiratory effort);
- oxygen saturation (if the patient has an oximeter);
- data from wearable devices
- other symptoms (eg, related to chronic disease);
- progress/deterioration (monitoring, review and follow-up; multiple consultations are possible per day and from day to day without the patient leaving home);
- mental state (mood, anxiety, suicide risk);
- situation at home (support, carer, family, food and supplies);
- relationships (especially screening for domestic violence);
- financial issues (unemployment, government payments, sick leave).
The patient who has poor indicators on history or indirect physical examination, and the patient who is deteriorating over a period of monitoring, should be sent to the emergency department. The patient should be advised to call triple-zero, and they should be reminded to wear a mask. Patients who do not have ambulance cover or entitlement to free ambulance transport may decline the advice to call 000. These patients should be advised that transport by ambulance is the safest and most appropriate option. Certainly, patients must not drive themselves to hospital.
MBS and the future of telehealth
At a time when the argument can be made that video consultations are the ideal way for GPs to treat patients with COVID-19, patients awaiting the results of their COVID-19 test, patients who are in vulnerable groups, or patients who may avoid medical care out of fear of COVID-19, the future of MBS telehealth item numbers is unclear.
At this stage, the COVID-19 temporary MBS telehealth service item numbers are due to expire on 30 September. However, the Australian Medical Association, the Australian College of Rural and Remote Medicine, and the Royal Australian College of General Practitioners have been advocating on behalf of GPs for the retention of telehealth services.
Since the introduction of the COVID-19 temporary MBS telehealth service item numbers in March 2020, telehealth has evolved to become an integral part of general practice. Telehealth will have a developing and ongoing role in the future of general practice, with or without COVID-19.
The Australian Government must recognise this, by retaining and enhancing telehealth in general practice.
GPs should consider increasing their use of video for consultations for patients who have COVID-19, and for patients across the spectrum of general practice. GPs have a role in providing support and advocacy for their patients to use video for consultations.
Dr Andrew Baird is a GP at the Elwood Family Clinic in Victoria. He is a tutor in professional practice for medical students at the University of Melbourne.
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.